Stanford Self-Management Programs Sample Master Trainer Agreement and Authorization

The [name of program] Program ("Program") was created by Dr. Kate Lorig, Diana Laurent, and Virginia González at Stanford University to teach patients how to manage their physical conditions.

Stanford presently conducts training sessions for health care professionals to become Program Leaders. Program Leaders are qualified to guide patients through the Program. Stanford also conducts training sessions for health care professionals to become Master Trainers of Program Leaders. A Master Trainer is qualified to teach Program Leaders how to guide patients through the Program.

As a qualified Master Trainer, Stanford grants you permission to train Program Leaders for health education purposes subject to the terms and conditions stated in this letter, including that:

1. Before you may train any individual as a Program Leader, you must ensure that the organization which employs that person or uses that person as a volunteer has a license to use the Program from Stanford. The license application can be accessed at http://patienteducation.stanford.edu/licensing/license_app.pdf.

2. You charge individuals whom you train only a reasonable cost-reimbursement fee for your training.

3. You provide Stanford an annual report listing the organizations whose employees or volunteers you have trained as Leaders and the cost reimbursement fee you charged. This report is due each year on the anniversary of the date of this letter.

4. While you are granted permission to reproduce copies of the Program materials for use in your training, Stanford retains ownership of the copyright to the Program. You agree that all copies of the Program materials contain the proprietary notice "Copyright © [YEAR OF COPYRIGHT], Stanford University" on the flyleaf of the Program.

5. Except with respect to any copyright notice provided in paragraph 4 above, you make no use of any name or insignia used by Stanford University or any of its related institutions without the express written consent of Stanford University.

6. You provide Program Leader training at your own risk. Stanford will not be liable for any damages with respect to any claim by you or any third party on account of your conducting of Program Leader training, your use of the Program, or your use of the Program materials, and you will indemnify and hold Stanford University harmless from any claims related to your conducting of Program Leader training, your use of the Program, or your use of the Program materials.

To remain an authorized Master Trainer, you must conduct at least one (1) leaders training or self-management workshop per year.

Stanford may terminate this permission at its discretion at any time upon written notice to you.

If you agree to the terms set forth above and have facilitated at least two (2) [Name of Program] workshops , please sign this letter in the space provided and return it to the Stanford Patient Education Research Center, 1000 Welch Road, Suite 204, Palo Alto CA 94304, ATTN: Master Trainer Authorization. The agreement/authorization will be countersigned by Dr. Lorig and a copy returned to you. You may not conduct Leaders's Training until you have received the final, signed document.

I, ___________________________, have facilitated at least two (2) [Name of Program] workshop. I agree to and acknowledge the above

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Dates trained as Master Trainer: SAMPLE ONLY

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Countersigned by Stanford University:

__________________________________________________________
Kate Lorig, R.N., Dr.P.H.
Professor

Effective date of authorization: