VDLUNTARY RESULUTIUN AGREEMENT BETWEEN THE LLS. DEPARTMENT UF HEALTH AND HUMAN SERVICES DFFICE FDR RIGHTS and THE BUARD 0F TRUSTEES 0F MICHIGAN STATE UNIVERSITY, dfbfa MICHIGAN STATE UNIVERSITY and MSU HEALTHTEAM, and MEU HEALTH INC. I. Inr in The parties to this Voluntary Resolution Agreement (the ?Agreement") are the United States Department of Health and Human Services Office for Civil Rights the Board of Trustees of Michigan State University dg?pfa Michigan State University and MSU HealthTeam HealthTeam") and MSU Health Care, Inc. Health Care"). For purposes of the Agreement, MSU, MSU Health Care and MSU HealthTeam are hereinafter collectively referred to as ?the MSU Entities." HHS DER and the MSU Entities shall together he referred to as the ?Parties." MSU is a University located in East Lansing, Michigan, and is governed by its Board of Trustees. MSU HealthTeam is the multl-specialty medical practice of with approximately 26f] physicians, nurse practitioners, and physicians? assistants in more than 4'3 clinics. HealthTeam is part of MSU, but is in the process of being restructured and will be folded into Health Care, a non-profit corporation that operates separately of MSU. The expected date of completion of the restructuring of MSLJ HealthTeam is July 1, EURO. MSU Health Care is governed by its Board; its sole member is MSU. This Agreement resolyes OCR Transaction Number 13-3051155. Lawrence G. Nasser was en osteopathic physician employed by MSLJ. Based on the criminal inyestigetion of Mr. Nasser for the sexual abuse of his patients and others, DER initiated an inyestigetion of MSU to determine if its doctors? offices and clinics yioleted Title IX of the Education Amendments of 197'2 and Section 1557r of the Affordable Care Act.1 A. ggriggiggign: DER is responsible for enforcing Title of the Education Amendments of 1912, as amended, 25 1551 et seq., and its implementing regulations at 45 C.F.R. Part 55 (?Title Title IX prohibits discrimination on the basis of sex in Federally-assisted education programs or ectiyities. DER. also enforces Section 155? of the Affordable Care Act 42 U.S.C. 18115, and its implementing regulations at 45 C.F.R. Part 92 (?Section Section 155? prohibits discrimination on the basis of race, color, national origin, sex, age and disability in any health program or ectiyity, any part of which receiyes Federal financial assistance Under Title and Section 155?, DER has the authority, where appropriate, to negotiate and secure yoluntery compliance agreements, and to bring enforcement actions which may include edministretiye proceedings to suspend, terminate or refuse to grant or continue HHS financial assistance to the coyered entity should DER fail to secure yoiuntery compliance. MSLI HealthTeam, and NSU Health lCare, as successor to MSU HealthTeam, receiye or will receiye, during the term of the Agreement FFA from HHS end are subject to or anticipate being subject to the requirements of Title IX and Section 1557'. MSU receiyes FFA and is subject to the requirements of Title IX. Pur?gge of Agreemgng: To resolye these matters without further burden or the expense of litigation, the MSU Entities agree to the terms stipulated in this Agreement and affirm that they will comply with all applicable proyisions of Title IX and Section 155?. The promises, obligations or other terms and conditions set forth 1 On February 5, 2013, after entering a guilty plea in Eaton County, MI, Mr. Nesser was sentenced to 40 to 125 years in prison for seven counts of felony criminal sexual conduct in the first degree. Mr. Nasser also has been conyicted in Federal court, as well as otherjurisdictions. 2 in this Agreement constitute the exchange of valuable consideration between the parties. II. Definiti??e For the purposes of this Agreement, the terms listed below shall have the following meaning: A. ?Patient" means anv individual who is seeking or receiving health care or ether medical services from MSU HealthTeam or MSLJ Health Care, or from MSU HealthTeam Staff or MSU Health ISere Staff. Staff," Health Care Staff? andg?ur Staf mean emplovees andfor contractors under the supervision or control of MSU HealthTeam or MSU Health Care, whether paid or unpaid, including but not limited to phvsicians, administrators, admissions and marketing personnel, directors of nursing, advanced practice registered nurses registered nurses (Finis), licensed practical nurses (LPNs), certified nurse aides (CNAs) and medical assistants. Collectivelv, all of these individuals will be referred to as ?Staff". means the functions which comprise MSU HealthTeam; and MSU HealthTeam?s successors, including but not limited to MSU Health Care. General Pruvieiene A. El. Suseension of Admini?rative Actions: Subject to the MSU Entities? continued performance of the stated obligations and required actions contained in this Agreement and in conformitv with Section Failure to Complv with the Agreement, OCR. shall suspend administrative action on OCR. Transaction Number 13- EUEUDB. Effective Qeie and Term ef the EQIEEWEHII This Agreement shall become effective on the date it is signed bv all parties {the ?Effective Date?). This Agreement will be in effect for three vears after completion of the obligations set forth in Section I?vr of this Agreement, at which time if HHS determines that the MSU Entities completed all actions required bv the Agreement, review and monitoring of the Agreement shall end. Notwithstanding the Term of this Agreement, the MSU Entities acknowledge theirr have a responsibilitv to compiv with Title IX and the analogous non?discrimination provisions of Section 155? for so long as thev continue to receive FFA. C. to with the Agreement: If DEF: determines the MSU Entities have failed to complv with anv provision of this Agreement, the parties will confer and attempt to reach agreement as to what steps mav be necessarv to resolve the compliance issues. If an agreement is not reached, DER mav terminate this Agreement within thirtv (3D) calendar davs' notice and take appropriate measures to effectuate the EntitiesF compliance with Title and Section 155?. Such measures mav include DER reopening DCFE. Transaction Number IB-BDEDGB. If OCR Transaction Number 18-3USDUS is reopened, OCR mav consider anv evidence of noncompliance with this Agreement and anv evidence obtained bv OCR prior to the signing of this Agreement. DER mav also exercise all rights available under Title IX and Section 155?, including, but not limited to, issuing noncompliance findings and initiating necessarv enforcement proceedings. D. Effeg]; gn cher Matters: The terms of this Agreement do not to anv other issues, reviews, investigations or complaints of discrimination that are unrelated to the subject matter of this Agreement and that mav be pending before DER. Anv unrelated compliance matter arising from subsequent reviews or investigations shall be addressed and resolved separately. Nothing in this Agreement shall be construed to limit or restrict statutorv and regulatorv authoritv to conduct future complaint investigations and compliance reviews related to the MSU Entities. This Agreement does not address or resolve issues involved in anv other complaint investigation, compliance review or administrative action under Federal laws bv other Federal agencies, including anv action or investigation under Title IX. Anv compliance matter arising from subsequent or separate reviews or investigations bv OCR shall be addressed and resolved independentlv, including but not limited to matters arising under the Health Insurance Portabilitv and Accountabilitv Act of 1996 (HIPAA), Pub. L. No. 14-191, 110 Stat. 1936 (1996} {codified in scattered sections ition A ainst Retaliation an Int' The MSLJ Entities shall not retaliate, intimidate, threaten, coerce or discriminate against anv person who has filed a grievance or complaint or who has assisted or participated in the inyestigation of any matter addressed in this Agreement. 'Ry' ft Ent' Ii wihh Agreement: DER may reyiew the MSU Entities' compliance with this Agreement at any time while the Agreement is in effect. As part of such reyiew DER may require written reports. access to witnesses, copies of documents andi'or inspections of the MSU Entities. In addition to any record keeping requirements of Title IX and Section 155?, throughout the duration of this Agreement the MSU Entities agree to retain the records required by OCR to assess their compliance. OCR will maintain the confidentiality of all documents, files and records receiyed from the MSU Entities and will not disclose their contents except where necessary in formal enforcement proceedings or where otherwise required by law. G. Acknowledgement of Comgletion: DER will proyide written acknowledgment to MSU of the completion of its obligations under Section IV of this Agreement. H. Non-waiver Provision: DCR's failure to enforce this entire Agreement or any proyislon thereof with respect to any deadline or any other proyision shall not be construed as a waiyer of right to enforce other deadlines or any proylsions of this Agreement. I. Entire Agreement: This Agreement constitutes the entire understanding between the MSU Entities and DER. in resolution of DEF. Transaction Number 186061308. Any statement, promise or agreement not contained herein shall not be enforceable through this Agreement. J. Mgdifieegien of Agreement: This Agreement may be modified by mutual agreement of the parties in writing. It. Publication or Relegse gf agreement: DCR places no restrictions on the publication of this Agreement. L. Thirg Party: Rights: This Agreement can be enforced only by the parties specified in this Agreement, their legal representatiyes and assigns. This Agreement shall be unenforceabie by third parties and shall not be construed to create third party beneficiary rights. M. Assistange: CCR will provide appropriate technical assistance to the MSU Entities regarding compliance with this Agreement, as requested and as reasonablv necessarv. N. Authority of Signer: The individuals who sign this Agreement on behalf of the MSU Entities represent that thev are authorized to bind MSU, MSU HealthTeam andfor MSU Health Care to the Agreement. Seven-ability: In the event that a court of competent jurisdiction determines that anvr provision of this Agreement is unenforceable, such provision shall be severed from the Agreement and all other provisions shall remain valid and enforceable; provided however that if the severance of anv such provision materiallv alters the rights or obligations of the parties, thev shall, through reasonable good faith negotiations, agree upon such other amendments hereto as mav be necessarv to restore the parties as closelv as possible to the relative rights and obligations initiallv intended to them hereunder. P. Binding on Successors: This Agreement is binding on the MSU Entities and their successors, and the MSU Entities are obligated to notifv ali successors of the existence and terms of this Agreement. Q. Contact Persons; The parties herebv designate the following persons as contacts for anv notice, report or document required bv this Agreement, except as otherwise mav be required; 1. For the Eiffice for Civil Rights Steven M. Mitchell Regional Manager Midwest Region Office for Civil Rights US. Department of Health E: Human Services 233 N. Michigan Ave., Suite 24D Chicago, IL 60601 Phone: {815} 425??2?8 2. For the Board of Trustees of Michigan State Universitv dfbfa Michigan State Universitv Dianne Eivrum Chair, Michigan State Universitv Board of Trustees Eiffice of the Secretaryr of the Board of Trustees Michigan State University?r 426 Auditorium Road Hannah Administration Building, Room 45:] East Lansing MI 48824-1?4? 3. For the Board of Trustees of Michigan State Universitv dfbfa MSU HealthTeam MSU HealthTeam Attn: Michael A. Herbert Chief Executive foicer Alliance, Suite Lansing, MI 48910 4. For MSU Health Care, Inc. MSU Health Care, Inc. Attn: Michael A. Herbert Chief Executive Officer Alliance, Suite Lansing, MI 4891!] IV. Obligations A. Applicability; The requirements of Part Iv of the Agreement are, unless otherwise noted, applicable to services provided bv, and facilities of, MSU HealthTeam and, thereafter, to its successors, including MSU Health Care. B. Notifica ion fChan hi: i nal or eration Status: The MSU Entities will provide written notice to DER if anv organizational or operational change affects or pertains to health care services or health care facilities currentlv operated under the MSU HealthTeam umbrella and is expected to affect MSU's Title I): or Section 155? policies or procedures. E. tice rimination: Within sixtv (SD) calendar davs of the Effective Date of this Agreement, MSU HealthTeam will revise its Notice of Non-Discrimination applicable to MSU HealthTeam?s services and to: . Contain sufficient information to inform individuals of their protections under Title I): and Section 155?; . Notifv individuals that MSU HealthTeam and its affiliates and subsidiaries do not discriminate on the basis of sex; and that Title IX and Section 155? protect both women and men from discrimination on the basis of sex (including but not limited to sexual harassment, sexual abuse andg?or sexual assault); . Notifv individuals of their right to file a Title or Section 155? grievance or complaint, and sufficientlv describe the MSU HealthTeam complaint process to facilitate the filing of complaints; . Inform individuals that inquiries regarding the application of Title IX andfor the analogous non-discrimination provisions of Section 155? mav be referred to Title IX Coordinator, who will serve as designated responsible emplovee to coordinate its efforts to complv with Title I): and the analogous non? discrimination provisions of Section 155? and oversee the acceptance and processing of grievances or complaints of sex discrimination; Ciffice of Institutional Eduitv andy?or Health Care Civil Rights Specialists; . Contain the name, title, office address, and the business email and telephone number of the Title IX Coordinator and each of the Health Care Civil Rights Specialists; . State that individuals also have the right to file complaints with the US. Department of Health and Human Services, Ciffice for Civil Rights. . MSU HealthTeam shall post the Notice of Non?Discrimination: a. In conspicuouslvwisible font size in publications and communications targeted to patients, consumers, students and members of the public; b. In conspicuous phvsical locations where MSLJ HealthTeam interacts with the public; and c. In a conspicuous location on the MSU HealthTeam?s website and each MSLJ HealthTeam facility website, if applicable, as well as the home page of website. d. In each MSU HealthTeam facility's or clinic's patient welcome letter andfor welcome packet. e. For significant publications and significant communications that are small?sized, such as postcards and tri?foid brochures, MSU HealthTeam shall post, in a conspicuously? visible font size the statement that MSLI HealthTeam does not discriminate on the basis of race, color, national origin, sex, age or disability in its health program or activities. 8. MSU HealthTeam will not satisfy this provision by solely adoptng or incorporating now?existing Title IKfSection 155? Notice of Non-Discrimination. 9. Organizational or operational changes affecting or pertaining to the Notice of NonhDiscrimination must be reflected in an amended version of the Notice of Non-Discrimination, posted within thirty (30) calendar days of the organizational or operational change. E1. Policies and Within sixty (ED) calendar days of the Effective Date of this Agreement, the MSU Entities will submit to DER for approval revised policies and procedures they have established to ensure Patients, Staff and other individuals are not discriminated against by MSLJ HealthTeam on the basis of sex, consistent with the requirements of this Agreement as well as Title IX and Section 155?. These policies and procedures shall include: the Notice of Non-Discrimination, revised in accordance with this Agreement; and the University Policy on Relationship violence 3L Sexual Misconduct Policy, including all appendixes, revised in accordance with this Agreement Policy"). The revised Notice of Non-Discrimination and the revised Policy will be disseminated to each new Patient; and posted on the MSU Health Team's website and each MSU HealthTeam facility website, if applicable, as well as the home page of website. The revised RUSH Policy will: 1. State that the Policy applies to the processing of all grievances or complaints of sex discrimination (including but not 9 limited to sexual harassment, sexual abuse andg?or sexual assault} filed bv Patients, Staff or other individuals related to MSU HealthTeam {?HealthTean-i complaints?): a. Ciarifv and define the conduct prohibited bv Title IX and Section 155??s prohibition against sex discrimination, where and to whom Patients, Staff and other individuals can file grievances or complaints of sex discrimination, including but not limited to the Title IX Coordinator, the Health Care Civil Rights Specialists, DIE, the Michigan State Universityr Police Department Police") and DER, and the procedures to be followed in connection with reports of sex discrimination; b. Explain that MSU strongiv encourages ant,?r Patient, Staff or other individual who feels he or she has been subjected to sex discrimination to immediatelv contact the Title IX Coordinator, or a Health Care Civil Rights Specialist, DIE, or the MSU Poiice; c. Provide for joint training and regular communication between MSU Entities and the MSU Police on the investigation of sex discrimination grievances and complaints; d. State that the MSU HealthTearn has a policv regarding patient privacv, chaperones, and informed consent {?Chaperone Policv?). MSU will revise the Chaperone Policy in conformance with this Agreement; include the revised Chaperone Policv as an appendix to the Poiicv; and post, on its websites (as described above), the revised Chaperone Policv, as an appendix to the avsn Policv. The revised i'jhaperone Polic?vr will require that: i. Staff will secure informed consent before initiating ?sensitive examinations" examinations, procedures or therapies where the Patient is disrobed, in full or in part, and there is exposure of the breasts, genitalia or rectum); and that if the Patient lacks decision making capacitv or declines to participate in making decisions, the MSU HealthTeam Staff will secure the consent of the Patient?s guardian; l? vi. vii. . HealthTeam Staff, when cenducting sensitive examinatiens, will fellew Universal Precautiens; MSU HealthTeam Staff, when cenducting sensitive examinatiens er previding ether medical treatment, will previde the Patient with: an explanatien ef the required examinatien, precedure er therapv befere beginning; an apprepriate gewn; privacv fer undressing and dressing; and sensitive draping te maximize privacv; MSLJ HealthTeam Staff, when sensitive examinations er previding ether medical treatment, will alwavs hener the Patient?s request te have a Suppert Persen present, including but net limited te a parent, relative er friend; Patients andfer their parents er Supperl: Persens, as well as Previders, mav request a chaperene at anv time. The Patient's wishes and cemfert sheuld determine the sex ef the chaperene. The MSU HealthTeam Staff shall accemmedate, te the extent practicable, the Patient?s request fer a same?sex chaperene; a Chaperene is required fer all sensitive examinatiens; fer sensitive examinatiens ef patients 10 vears ef age er greater, a lChaperene must be an autherized member ef the health care team; the use ef a Chaperene fer sensitive examinatiens must be decumented in each Patient's medical recerd; ifa Patient declinesfrefuses a Chaperene fer an examinatien where ene is required, the previder must decument in the recerd that an effer was made and declined, and the Patient er guardian must sign a waiver; the phvsical examinatien ef an infant, teddler, er child sheuld alwavs be perfermed in the presence ef a parent er guardian; if a parent er guardian is unavailable er the parent?s presence will interfere with the phvsical examinatien, such as in a pessible case ef abuse er parental mental health issues, an 11 authorized member of the health care team should be present during the physical examination; and MSU HealthTeam Staff, when conducting sensitiye examinations, will always honor the Patient?s request to haye a Chaperone present, eyen when the patient also has a Support Person present. 2. MSU HealthTeam will work with OCR to adjust or amend these proposed policies and procedures to address any comments and concerns identified by DER. Within thirty {30] calendar days after receiying submission, DER shall approye or request further reyisions of policies and procedures. Within thirty [30) calendar days after approyal by DER, the MSLJ Entities shall implement the policies and procedures and distribute, by mail, email, or other means, the reyised policies and procedures, to all MSLJ HealthTeam Staff. 3. The MSU Entities will not satisfy this proyision by merely adopting or incorporating now-existing Title IKfSection 1557i policies and procedures. 4. Drganizational or operational changes affecting or pertaining to the RVSM Policy must be reflected in an amended yersion of the RVSM Policy and procedures within thirty [30} calendar days of the organisational or operational change, which must be distributed by mail, email or other means to applicable staff within thirty {30} calendar days of the organizational or operational change. E. Health Care Ciyii RitII'Its Specialiggs: Title IX Coordinator will designate an employee or employees responsible for each building that contains a HealthTeam clinic to serye as a Health Care Ciyil Rights Specialist (?Specialist?) for that building. Indiyiduals who haye Title IX or Section 155?f grieyances or complaints pending against them will not be eligible to serye as a Specialist. The Specialists? duties shall include receiying grieyances or complaints of sex discrimination and assisting the Title IX Coordinator with training, monitoring, and ensuring compliance with this Agreement. 1. The Specialists will be employees of Office for Ciyil Rights and Title IX Education and Compliance and will not be any person who has preyiously seryed {or is currently serying) as the Title IX Coordinator or its eduiyaient with the MSU Entities. 11 F. 2. The Title IX Coordinator will develop educational materials for MSLI HealthTeam Staff during the term of this Agreement. 3. The Specialists will work with the Title IX Coordinator to train MSU HealthTeam Staff in their responsibilities under Title IX and Section 155?. 4. The Specialists will be available to advise MSU HealthTeam Staff regarding their obligation to report incidents of sex discrimination and assist in reporting. Grievance Progegures and Dggic?ted Health Care All grievances or complaints alleging SEX discrimination, filed bv Patients, Staff or other individuals related to MSU HealthTeam, will be reviewed and investigated bv, or under the supervision of, a dedicated Health Care Investigator emploved or engaged bv DIE. 1.Within ninetv calendar davs of the Effective Date, DIE shail engage a qualified, objective, independent health care investigator to review, investigate, and resolve all MSU HealthTeam grievances or complaints from anv source alleging in part or in whole sex discrimination prohibited bv Title andfor Section 155?. The Title IX Coordinator will submit to DER for approval a list of three proposed candidates to serve as the Health Care Investigator; these candidates mav be individuals or entities. The submission shall include the candidates? curricolum vitae and other appropriate background information demonstrating expertise in the area of monitoring and investigating compliance with federal or state statutes and regulations, including civil rights statutes and regulations. Within thirty (30} calendar davs after receiving submission, DER shall approve or disapprove of such candidates in writing. Within thirtv {30} calendar davs of its receipt of approval, DIE shall then hire one of the candidates from the approved list and inform DER. of its selection in writing. 2.The Health Eare Investigator will follow the procedures for review, investigation and resolution of grievances and complaints outlined in Notice of NonFDiscrimination and revised RVSM Policv. grievance and complaint procedures will complv with Title IX's and Section 155?'s prohibition of seat discrimination, and this Agreement. 13 a. When a grievance or complaint based in whole or in part on Title IX andg?or Section 155?, is submitted, the Health Care Investigator will: i. Interview complainants, witnesses, MSU HealthTeam Staff and affiliates as needed; ii. Review all information relevant to the grievance or complaint; Make determinations about the grievance or complaint; and iv. Request MSU HealthTeam impose disciplinarv actions on staff who have been found to have violated the Title IX andfor Section 155? policies and procedures established under this Agreement, or anv other term of this Agreement. This shall include referrals to law enforcement agencies, where appropriate. b. For three vears after his or her engagement, the Health Care Investigator shall provide bi-annual reports to OCR and MSU HealthTeam bv Januarv 31 and June 3b of each year. c. For three vears, the Title IX Coordinator or their designee shall submit an Annual Report to and MSU HealthTeam, which reviews MSU Entities? overall compliance with this Agreement and their obligations under Title IX and the analogous nonndiscrimination provisions of Section 155?. Each Annual Report shall include recommendations for necessarv revisions to the revised Notice of Non-Discrimination, pursuant to Section IRAC. of this Agreement; the revised Policv, pursuant to Section the Training Program materials, pursuant to Section and the Grievance Form, pursuant to Section i, The first Annual Report is due bv August 30, 2020. ii. The second Annual Report is due bv August 30, 2?21. The third Annual Report is due bv August 3D, BUZZ. 111- d. Within thirty {30) calendar days after the submission of each Annual Report, the HealthTeam Contact Person may submit to OCR a written response. OCR may, but is not required to, comment on any of the Annual Reports andXor any response from the MSU HealthTearn Contact Person. e. The Health Care Inyestigator and the MSU Entities shall retain and malte to OCR, upon DCR's request, all work papers, supporting documentation, correspondence and draft reports related to each HealthTeam grieyance or complaint. f. MSU may not terminate the Health Care Inyestigator except for cause and may only do so with consent. i. In the eyent that MSU Entities seek to terminate a Health Care Inyestigator, the MSU Title IX Coordinator shall proyicle a written statement to setting forth in detail the basis for the request. 1. If CJCR agrees that the current Health Care Inyestigator should be terminated, OCR. will inform the Title IX Coordinator in writing, and MSU Entities will be authorized to terminate the current Health Care Inyestigator. 2. If GCR concludes that cause does not exist for the remoyal of the Health Care Inyestigator, it shall inform the Title I): Coordinator in writing and the Health Care Inyestigator shall remain in place. ii. If the termination does occur, the Title IX Coordinator shall nominate a replacement Health Care Inyestigator in accordance with Sections of this Agreement within twenty {Elli} calendar days of the termination. In the eyent that the Health Care Investigator resigns while the Agreement is still in effect, the Title IX Coordinator shall nominate a replacement Health Care Inyestigator using the process set forth in Sections W.F. 15 iv. Nothing in this agreement, including unavailabilitv of a Health Care Investigator for anv reason, shall prevent MSU from and equitablv responding to all incidents of sex discrimination of which it has notice; take prompt and effective steps to and sexual or genderabased harassment, assault or violence; eliminate anv hostile environment; prevent its reoccurrence; and remedv the discriminatorv effects on the victim and others as appropriate. If the Health Care Investigator is unavailable for anv reason, the Title IX Coordinator mayr engage another qualified investigator to perform the duties of the Health Care Investigator. g. In the event that in its discretion, determines or has reason to believe that the Health Care Investigator: does not possess the expertise, independence or objectivitv required bv this Agreement; has failed to carrv out its responsibilities as set forth in this Agreement, DCR mav, at its sole discretion, send notice to the Title Coordinator to engage a new Health Care Investigator in accordance with Section h. 0n the third anniversarv of the Health Care Investigator's engagement, the Title I): Coordinator mav assign HealthTearn investigations using its discretion and release the Health Care Investigator from further duties. S. Grievangg Fgrm: Within ninetv (9U) calendar davs of the Effective Date, the Title IX Coordinator shall prepare a form for the filing of all sex discrimination grievances or complaints related to MSU HealthTeam. The Title IX Coordinator shall submit the form to Within thirtv calendar davs of receiving the Grievance Form, shall approve or request further revisions. Within thirtv {30) calendar davs of its receipt of DCR's approval, the Title IX Coordinator shall adopt and publish the Grievance Form. The form must include: 1. Sex DiscriminationfSexual Harassmenthexual AbusefSexual Assault as tvpes of incidents for individuals to identifv as violations of Title IX and Section 155?; IE 2. A statement that retaliation and retaliatoryr harassment is prohibited against anv individual who Files a grievance or complaint or who participates in a grievance or complaint investigation in anv wav; 3. Contain the name, title, office address and business email address and phone number of the Title IX Coordinator, DIE, and each Specialist; and 4. State that individuals also have a right to file a complaint with the US. Department of Health and Human Services, Office for Civil Rights. 5. The MSU Entities will not satisfv this provision bv merelvr adopting or incorporating now-existing discrimination complaint form. 6.Drgani2ationa or operational changes affecting or pertaining to the grievance form must be reflected in an amended version of the Grievance Form within thirty {30} calendar davs of the organizational or operational change. H. Irainiug; The Title IX Coordinator or his or her designee will create and implement a mandatorv Title IXfSection 1557' training program applicable to MSU HealthTeam services and facilities (?Training Program") for all MSU HealthTeam Staff. 1. The Training Program shall include general instruction on compliance with Title IX and the analogous non-discrimination provisions of Section 155?. 2. The Training Program shall also include training on all of the new and revised policies and procedures described in Section of this Agreement. 3. Within ninetv (SD) calendar davs of CiCFt?s final approval of the policies and procedures described in Section the Title IX Coordinator shall submit the proposed training materials for GCR's review. 4. Within thirtyr (3U) calendar davs after receives submission, OCR will inform MSU Entities in writing as to whether or not DCP. approves or disapproves of the proposed training materials. ?13" 5. If IIZJCR does not approve. DCR will provide the Title Coordinator with written comments and recommendations in order for MSU to prepare accEptable, revised training materials. 5. MSU will have thirtv (3D) calendar davs from the date it receives notice of disapproval to revise the training materials accordinglv and submit the revised training materials to DCP. for review. This submission and review process will continue until approves the training materials. Within one hundred eightv [18m calendar davs of approval of training materials, the Title IX Coordinator shall provide the approved training to all active MSU HealthTeam Staff. a. The Title Coordinator or their designs-e shall train MSU HealthTeam Staff who were absent from the active workforce during the initial training and return to the active workforce after the initial training, within thirtv {30) calendar davs of their return to work. b. The Title IX Coordinator or their designee shall train anv staff who commence working for HealthTeam after the initial training, within thirtyr [30] calendar davs of their return or commencement of their emplovment or affiliation with HealthTeam. 8. The MSLJ HealthTearn shall keep record of the date of training for each staff member. WEE-LI HealthTeam shall retain records of staff training no less than six {Eu} vears following the date each training was provided. 9. The Title IX Coordinator shall review the Training Program as reasonable and appropriate but no less than annuallv. The Title IX Coordinator will update the Training Program to reflect anv material changes in policies and procedures, federal law. guidance, andXor material compliance issue(s) discovered during audits, investigations or reviews within a reasonable period of time after the material change becomes effective. It}. The Entities will not satisfv this provision bv soielv adopting or incorporating now-existing Title IXfSection 155? Training Program. 11. Organizational or operational changes affecting or pertaining to the provision of MSU HealthTeam?s services or HealthTeam facilities that affect Training Program materials will be reflected in 13 an amended versibn of the Training materials. which will be distributed to Staff at the next regularlv scheduled training. mammal-35 The individuals signing represent that thev are authorized to execute this Agreement and legallv bind the parties be the Agreement. x? . {Lyn-yufgt I: II 26-12? SDARD DF TRUSTEES ICHIGAN STATE Date dx?bfa MICHIGAN STATE Dianne Bvrum Chair, Michigan State Universitv Heard of Trustees BDARD DF TRUSTEES DF MICHIGAN STATE dsza MSU HealthTeam Michael A. Herbert Chief Executive foicer, MSU HealthTeam NSQM a/?Zallr MSU HEALTH CARE, INC. Date Michael A. Herbert Chief Executive foicer, MSU Health Care, Inc. 3.049 Dal: C: - Q?/cj/f? U. S. DEPARTMENT OF HEALTH 3L HUMAN Date DFFICE FDR RIGHTS Steven M. Mitchell Regienal Manager Midwest Region 19