Informed Consent

INFORMED CONSENT

PRE-DEPLOYMENT SCREENING
Instructions: Please complete the form below. The form is not complete until it is signed, dated, and submitted.
MY ASSIGNMENT:*

V1 - Dr. Susan
NAME:*

First NameLast Name
DATE OF BIRTH:*

MonthDayYear
Date
AGE:*
GENDER:*

MALEFEMALE
POSITION APPLYING FOR:*
AGENCY APPLYING TO:*
PLEASE BE INFORMED THAT ANY INFORMATION DISCLOSED DURING THE INTERVIEW, AS WELL AS INFORMATION ON THE SELF-REPORT QUESTIONNAIRE AND ASSESSMENTS, MAY BE COMMUNICATED TO THE AGENCY TO WHICH YOU ARE APPLYING TO IN VERBAL COMMUNICATION OR A FINAL WRITTEN SUMMARY.

YOU MUST UNDERSTAND THERE IS NO CONFIDENTIALITY IN THIS EVALUATION.

I HAVE READ AND UNDERSTAND THE PRECEDING INFORMATION. I UNDERSTAND THERE IS NO CONFIDENTIALITY IN THIS EVALUATION AND THE INFORMATION FROM THE INTERVIEW AND THE QUESTIONNAIRE WILL BE RELEASED TO THE AGENCY TO WHICH YOU ARE APPLYING TO.
SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
Should be Empty:

INFORMED CONSENT