Bob: Here is the consent form we use for our practicum with the nearby state
hospital. It obviously was prepared by the legal staff.
Psychology Capstone Practicum 4143
STUDENT ACKNOWLEDGMENT AND RELEASE
THIS ACKNOWLEDGMENT AND RELEASE is made by__________________,
effective on the date when signed and witnessed below.
WHEREAS, the undersigned student has been allowed to enter into a
practical educational program involving the University of Oklahoma and
Griffin Memorial Hospital, the student formally
agrees to and acknowledges his/her responsibilities while in the program.
NOW THEREFORE the undersigned understands and agrees:
1. To adhere to University of Oklahoma and Griffin
Memorial Hospital policies, procedures, programs,
practices and operating standards, as provided in the
course syllabus and hospital volunteer policy manual.
2. To operate under the direction and supervision of the
University and Hospital directors of the program.
3. To complete all documentation pertaining to the program
required by the University and the Hospital.
4. To prepare for and participate in regular evaluation
conferences, as may be required by the University and
Hospital.
5. To act in an appropriate and ethical manner at all
times when either directly or indirectly engaged in
program activities and to strictly preserve the
confidentiality of Hospital data.
6. To provide my own transportation to and from Griffin
Hospital and be responsible for my own health, accident, and automobile
insurance.
7. In the event of my injury, death or other damage to
myself or my property in connection with or resulting
in any way from my participation in this practical
educational program, I hereby release and indemnify the
University, it's regents, faculty, and staff and the
Hospital and it's directors and employees(Collectively,
"Releasees") from any liability for all claims,
damages, fees and/or costs related to any such injury,
death or damage save and except for Releasees'
negligent acts or omissions. It is my intent and
understanding that I am bound by this release as are
those who succeed to my rights, such as my heirs or
next of kin. I have indemnified Releasees, and waived
and released the above rights in return for the
opportunity given to me by the University and Hospital
respectively to participate in this practical
experience.
THE TERMS OF THIS ACKNOWLEDGMENT AND RELEASE ARE BINDING ON THE UNDERSIGNED
AND THIS DOCUMENT SHALL SERVE AS A RELEASE AND
ASSUMPTION OF THE RISK FOR MYSELF, MY HEIRS, ASSIGNS AND NEXT OF KIN.
AGREED:
Signature of student _____________________________Age_______
Date__________.
Signature of witness _____________________________Age_______
Date__________.
Signature of witness ____________________________ Age_______
Date__________.
THE TERMS OF THIS ACKNOWLEDGMENT AND RELEASE ARE BINDING ON THE UNDERSIGNED
AND THIS DOCUMENT SHALL SERVE AS A RELEASE AND
ASSUMPTION OF THE RISK FOR MYSELF, MY HEIRS, ASSIGNS AND NEXT OF KIN.
AGREED:
Signature of student _____________________________________Date
Signature of witness _____________________________________Date
Signature of witness _____________________________________Date
C. Eugene Walker, Ph.D.
University of Oklahoma, [EMAIL PROTECTED]
----- Original Message -----
From: "Dr.Bob Wildblood" <[EMAIL PROTECTED]>
To: "Teaching in the Psychological Sciences" <[EMAIL PROTECTED]>
Sent: Saturday, February 14, 2004 9:00 AM
Subject: Field Placement/Practica
> TIPSters,
>
> We are beginning to place more people in practica than we have in the
> past and the colleague with whom I share responsibility for supervising
> these practica and I have decided that we need to have a more formal
> way of dealing with these people than we have used in the past. I'd
> really appreciate it if you might give me some information about how
> you handle your practica. Anything that will help would be appreciated
> -- examples of "contracts" between the institution and the student, the
> student and the placement site, etc. would be great. We have a formal
> structure that has to do with malpractice insurance that the University
> provides for the student, but everything else is up for grabs.
>
> TIA
>
> Dr. Bob Wildlbood
> Lecturer in Psychology
> Indiana University Kokomo
> Kokomo, IN 56904-9003
> [EMAIL PROTECTED]
> [EMAIL PROTECTED]
>
>
> ---
> You are currently subscribed to tips as: [EMAIL PROTECTED]
> To unsubscribe send a blank email to [EMAIL PROTECTED]
>
----- Original Message -----
From: "Dr. Bob Wildblood" <[EMAIL PROTECTED]>
To: "Teaching in the Psychological Sciences" <[EMAIL PROTECTED]>
Sent: Saturday, February 14, 2004 9:00 AM
Subject: Field Placement/Practica
> TIPSters,
>
> We are beginning to place more people in practica than we have in the
> past and the colleague with whom I share responsibility for supervising
> these practica and I have decided that we need to have a more formal
> way of dealing with these people than we have used in the past. I'd
> really appreciate it if you might give me some information about how
> you handle your practica. Anything that will help would be appreciated
> -- examples of "contracts" between the institution and the student, the
> student and the placement site, etc. would be great. We have a formal
> structure that has to do with malpractice insurance that the University
> provides for the student, but everything else is up for grabs.
>
> TIA
>
> Dr. Bob Wildlbood
> Lecturer in Psychology
> Indiana University Kokomo
> Kokomo, IN 56904-9003
> [EMAIL PROTECTED]
> [EMAIL PROTECTED]
>
>
> ---
> You are currently subscribed to tips as: [EMAIL PROTECTED]
> To unsubscribe send a blank email to
[EMAIL PROTECTED]
>
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