Field Experience Handbook: Practicum and Internship

For Students, Site Supervisors and

School Counseling Faculty

School Counseling Program Department of Educational Psychology

College of Education University of Arizona

Practicum EDP 594b Internship EDP 593b

Compiled by Yvonne Clay

Practicum and Internship Supervisor August 2007

Last updated January 2008

2

Table of Contents

Page Number Introduction

3

Purpose of the Field Experience

4

Responsibilities of the Student

5

Responsibilities of the School Site Supervisor

7

Responsibilities of the University Supervisor

8

Forms Practicum/Internship Student Information School Site Placement Contract Practicum/Internship Log Supervision Log Practicum: School Site Supervisor Eval of Student Internship: School Site Supervisor Eval of Student School Site Visitation School Site Evaluation by Student University Supervisor Eval by Student Videotaping permission – English Videotaping permission – Spanish

10 10 11 12 13 14 16 1920 21 23 24

University of Arizona Sexual Harassment and Grievance Policies

25

3

INTRODUCTION

The Master of Education program in School Counseling in the Department of Educational Psychology at the University of Arizona is designed to prepare students to obtain the Arizona pre-K-12 school guidance and counseling certification and to deliver a comprehensive school counseling program. The program provides learning experiences the elements of a comprehensive school counseling program: individual student planning, responsive services and system support. Courses in the program address the role of the school counselor as a contributor to student academic achievement and success. The faculty in the School Counseling Program consider supervised field experiences (i.e., practicum and internship) to be among the most important professional preparation activities in which the students participate. Students are required to complete 100 clock hours of practicum and 600 clock hours of internship. Internship is generally 300 hours per semester over two university semesters. Students are encouraged to work at all three levels; elementary, middle school and high school. Before enrolling in Practicum, students must complete EDP 530, (Professional Orientation to School Counseling) and EDP 535 (School Counseling Techniques; Pre-practicum) and receive approval from their advisor. Students must pass the practicum course, and complete EDP 536(Small Group and School Counseling) prior to enrolling in EDP 593b Internship. The internship is a more intensive experience wherein the student is expected to demonstrate broader skills in all aspects of professional functioning. Internship experiences should be at sites that are appropriate to students’ career goals. Once enrolled in either course students must present documentation of the current professional liability insurance. Membership fees for the American School Counselor Association include professional liability insurance. Students must also have documentation of State of Arizona, Department of Public Safety Fingerprint Clearance. These documents are given to the university supervisor, and a copy is kept in students’ files. Students and the University Supervisor will work together to make selection(s) for school sites for field experiences. When potential sites have been identified, students visit the site and meet with the site supervisor, who decides whether she/he is willing to take the student as a practicum student or intern. Each of the area school districts has different procedures for arranging these experiences: students should check with their advisor regarding the procedure in districts of interest. Portions of this document are based on materials from Governors State University, Northern Arizona University, Florida Gulf Coast University, Texas Women’s University, The University of Arizona, Clemson University, and The American School Counselors Association.

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Purpose of Field Experience

The purpose of the field experiences is to give students on-the-job training in the role of the school counselors. Students work in a school setting under the supervision of an experienced school counselor with a State of Arizona Pre-K-12 certification and at least two years school counseling experience. It is preferable that the supervising counselor be implementing a Comprehensive Competency-Based Guidance program aligned with the ASCA National Model. The guidelines and requirements for practicum and internship are based on the Council for Accreditation of Counseling and Related Education Programs (CACREP) standards. Students are involved in a variety of on-site activities. For example students may facilitate groups, teach guidance lessons, organize career days, and participate in staff development workshops. Students gain valuable experiences and broaden their depth of knowledge and experience in the school counseling profession.

5

Responsibilities of the Student Practicum students complete 100 clock hours. These must include 40 hours of direct service with students. Direct service is defined as services rendered when in direct contact with students and/or their caregivers. Internship students complete a total of 600 hours, usually 300 per semester over two semesters. The total hours must include 240 hours of direct service with students. Practicum and internship students will: 1. Provide their approved Application for Practicum and Internship. 2. Provide evidence of professional liability insurance. 3. Provide evidence of Arizona Fingerprint clearance. 4. Provide the contract signed by the student, the site supervisor, the school principal, and the

university supervisor. The contract is an agreement between the student and the site. 5. Adhere to the schedule established with site and to any dress or behavioral codes of the site. 6. Follow the school calendar of their site/school district as it relates to holidays, i.e., spring

break. 7. Make prior arrangements if they are unable to attend as scheduled. Students must inform

both their site supervisor and the university supervisor of absences. When there is an emergency that precludes prior arrangements of an absence, students will notify their supervisors at the earliest opportunity.

8. Conform to the rules and regulations of the school or school district and the ethical standards of the American School Counselors Association.

9. Keep an accurate daily log of activities at the site to include the delivery system categories the direct and indirect hours. Log is to be turned in at each seminar meeting to university supervisor.

10. Attend all scheduled seminar meetings (24 hrs) and follow the requirements in the syllabus, which includes all dates of seminars scheduled for the semester and other pertinent information. These hours count as indirect hours.

11. Schedule an on site visit/observation by university supervisor. 12. Meet individually with school site supervisor (internship) or university supervisor

(practicum) at least one hour per week to obtain feedback on your performance. 13. Provide video tapes of your counseling sessions for review by the seminar group or student

and the university supervisor. 14. Submit a University Supervisor evaluation form at the end of the practicum and end of the

internship. 15. Submit a Site Evaluation form and Site Supervisor form at end of field experience. 16. Ensure site supervisor mails a Site Supervisor Rating of Student Performance form to the

university supervisor at midterm and another one at end of practicum or internship field experience.

17. Be prepared to discuss the university supervisors and site supervisor evaluation of Student Performance at midterm and at end of semester.

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Supervision: ! Beginning January 2008 the following CACREP requirements for practicum

and internship supervisor will take effect:

o Practicum: 1.5 hours of group supervision per week (24 hrs per semester) and 1 hour of individual supervision per week with university supervisor.

o Internship: 1.5 hours of group supervision (24 hrs per semester) and one hour of individual supervision to be done on site by the site supervisor.

o Site visits: A minimum of 1 site visit per internship site per semester by the university supervisor. This visit is to be arranged with the university supervisor taking into account both supervisors’ needs and schedules.

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Responsibilities of School Site Supervisor 1. The practicum or internship site supervisor assists the student with developing the

Practicum/Internship Site Contract and Proposed Activities for the Delivery System in the Practicum and Internship at School Site. The supervisor orients the student to the school, staff, school goals and school mission. The site supervisor and the student decide on the schedule for the practicum or internship hours at the school site. This information is included on the Site Contract.

2. For the practicum experience, the student must complete a minimum of 100 hours, including at least 40 hours of direct service with students. Direct service includes individual, family consultation, group counseling and classroom interaction.

3. For the internship experience, the student must complete a minimum of 300 hours per semester, including a minimum of 120 hours of direct services with students. If the student is completing 600 hours in one semester, then a minimum of 240 hours of direct service is required.

4. The site supervisor meets with the internship student for a minimum of one hour per week for supervision, wherein student progress is discussed and the student’s learning experience is facilitated. Observations of the student’s work are discussed, with strengths and areas for improvement reviewed. The site supervisor permits audio/video taping when requested by student. Student will have permission forms available in English and Spanish for the parent or guardian to sign. The student will have weekly individual supervision with the university supervisor, in which work samples (videotapes and audiotapes) are reviewed. Students are expected to bring copies of these work samples for review in group supervision. Site supervision is recommended but not required for practicum students, as individual supervision will be offered by the university supervisor.

5. The site supervisor reviews the student’s log form, and indicates that the log is accurate by

signing and dating the form. In addition, a daily attendance log requires the site supervisor’s signature. This document is provided to the university supervisor at midterm and end of semester.

6. The site supervisor participates in the visitation by the university supervisor and completes the Site Visitation Form following the visit. The site supervisor maintains contact with the university supervisor via email, phone calls and in person meetings (at least one visit to the site each semester by the university supervisor) for consultation and to discuss student progress of the student.

7. The site supervisor maintains confidentiality (with the exception of the university supervisor) regarding information obtained during supervision with the student.

8. The site supervisor engages in ongoing assessment of the student’s performance and communicates with the university supervisor about any problems. If problems persist, the site supervisor, in consultation with the student and university supervisor, develop a remediation plan.

9. The site supervisor completes a midterm and final evaluation forms on the student and discusses the evaluation with the student. Forms are delivered to the university supervisor.

10. The site supervisor supports the professional development of the student by informing the student of activities (such as conferences and workshops) that will provide valuable learning experiences and the opportunities to interact with current school counselors.

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Responsibilities of University Supervisor

1. Review application for practicum and internship that has been approved by the student’s faculty advisor.

2. Discuss with students the level (elementary, middle school and high school) at which they prefer to be placed for the practicum and the two levels for the internship and determine whether the student has preferences for school district/s and/or schools.

3. Coordinate the placement of students in appropriate school settings in districts who prefer this procedure. Make contact with the director of counseling, counselor and or administrator of the school district to discuss placement of students for the field experience in districts where this procedure is used.

4. Be available to students throughout the year by conferences, phone calls and email to discuss their concerns regarding the field experiences.

5. Facilitate and support the professional development of the students by introducing them to resources, workshops, curricula, and school counseling publications including specific articles related to issues encountered in the field experiences.

6. Schedule and facilitate seminar meetings around the academic class schedule and students’ work schedule. In the seminar, students discuss their field experiences in order to learn from one another and to share lesson plans, obtain ideas for implementation, and receive feedback from one another. The university supervisor may schedule speakers relevant to the needs and requests of the students to enhance their field experiences and help prepare them for their role as a school counselor.

7. Review the Practicum and Internship Handbook for Students, School Site Supervisors and School Counseling Faculty at the first seminar meeting, and refer to it as needed. Point out to students that the Handbook is in lieu of a detailed syllabus for the course.

8. Collect completed Student Information Forms and request that students update it regularly as information changes.

9. Collect Log Sheets at each seminar meeting. Monitor the distribution of direct/indirect hours. 10. Ensure that the school site supervisor receives the Field Experience Handbook and reviews

requirements for the student and the supervisors. 11. Schedule, if needed, an on-site orientation with new supervisors to ensure understanding of

the requirements of the field experience. 12. Visit school sites at least once per semester to observe the student providing services to

students and to consult with the site supervisor regarding student progress. 13. Consult as needed with the student/school site supervisor regarding problems with the

student’s placement. 14. Obtain evidence of a student’s performance through direct observation, audiotape, videotape

and feedback from site supervisor. Provide effective and timely feedback on student’s performance to the student.

15. Provide the site supervisor with the Site Supervisor Evaluation Form and inform the site supervisor of due dates for any forms and Maintain records of student hours.

16. Practicum and Internship Seminars: The seminar is considered group supervision for both the practicum and internship. Eight sessions per semester equal 24 hours.

17. Beginning January 2008 the following CACREP requirements for practicum and internship supervisor will take effect:

a. Practicum: 1.5 hours of group supervision per week (24 hrs per semester) and 1 hour of individual supervision per week with university supervisor.

b. Internship: 1.5 hours of group supervision (24 hrs per semester) and one hour of individual supervision to be done on site by the site supervisor.

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c. Site visits: A minimum of 1 site visit per internship site per semester by the university supervisor. This visit is to be arranged with the university supervisor taking into account both supervisors’ needs and schedules.

18. Provide the students with information regarding job openings in school districts in Arizona. This includes possibilities for paid internships.

19. Collect the mid term Site Supervisor Evaluation of Student Performance form at the appropriate time, and the Student Evaluation of Site, Student Evaluation of Site Supervisor, Site Supervisor Evaluation of Student Performance and, Student Evaluation of University Supervisor forms at end of semester.

20. Complete the University Supervisor Evaluation of Student no later than the end of the second month of the experience and at the end of semester.

21. Determine final grade of student. 22. Turn in grades online as required by the University of Arizona. 23. Consult with the School Counseling and Guidance faculty regarding student performance

and other relevant information.

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University of Arizona, College of Education Educational Psychology Department

School Counseling Program Internship and Practicum Class

Student Information Form

Name: Date: Email Address: Residence Address: Home Phone: Cell Phone : Work Phone/Workplace Degree(s) Major/Minor College/University: Year: Placement for Internship/Practicum : Site Counselor Supervisor: Phone: Email Address : Days and Times at School Site: Time at School Site: Class at UA: _____________Day& Time _______________Instructor: Class at UA: _____________Day& Time _______________Instructor: Class at UA: _____________Day& Time _______________Instructor: Additional information:_______________________________________

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School Counseling Program Educational Psychology Department

College of Education, University of Arizona

EDP 594b Practicum/EDP 593b Internship

School Site Placement Contract

Student Name: Student Address: Zip: Student Email: Student Home Phone: Cell Phone: School Name: School Address: Zip: Principal: Email: Site Supervisor: Supervisor Phone : Email: Starting Date: Ending Date: Days at Site: Hours at Site: I agree to accept this University of Arizona practicum/internship student, and understand my role as site supervisor: Supervisor Signature: The practicum/internship student has my permission to complete a practicum/internship at: (school), under the supervision of (site supervisor). Principal Name and Signature: Date: Student Signature: Date: University Supervisor: Date:

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School Counseling Practicum/ Internship Log Sheet

Student’s Name Semester to School Site Supervisor’s Signature Dates of Page School

Date Time Activity Description Activity Type Number of Hours

Activity Type

A C F G I CG O SS US T

Weekly Hours

Cumul- ative hrs

Weekly Direct Contact: Weekly Non-Direct Hours: Cumulative Direct Contact: Cumulative Non-Direct Hours:

Legend:(items in bold are direct contact) A= Administrative C= Consultation/Staffing F= Family Consultation G= Group Counseling I= Individual Counseling CG=Classroom Guidance

O= Other Contact SS= Site Supervision US= University Sup.

T= Training

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Practicum/Internship Supervision Log

Student Supervisor_______________ School_________________________________________________________________

Date Hours Supervisor’s Initial Student Initial

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University of Arizona, College of Education Educational Psychology Department

School Counseling Program Practicum EDP 594b

School Site Supervisor Evaluation of Student Performance

Date: Name of Student: Site Supervisor: School: Please rate the student on the following scale: Unacceptable Marginally

Acceptable Acceptable Good Superior Not

Applicable 1 2 3 4 5

The practicum student … 1. was receptive to constructive

feedback. 1 2 3 4 5 n/a

2. was dependable and reliable 1

2 3 4 5 n/a

3. communicated about absence/tardiness.

1

2 3 4 5 n/a

4. was able to function without close supervision.

1 2 3 4 5 n/a

5. demonstrated professionalism in attire/appearance.

1 2 3 4 5 n/a

6. developed positive relationships w/other staff members.

1 2 3 4 5 n/a

7. exhibited developmentally appropriate counseling skills.

1 2 3 4 5 n/a

8. was flexible and able to meet the needs of the worksite.

1 2 3 4 5 n/a

9. showed growth and increasing independence

1 2 3 4 5 n/a

10. strived to gain increasing skills and knowledge.

1 2 3 4 5 n/a

11. demonstrated exemplary ethical behaviors.

1 2 3 4 5 n/a

12. completes total number of hrs/days in a timely manner.

1 2 3 4 5 n/a

13. used teaching and learning strategies that reflected sensitivity to students’ cultures, learning styles, special needs and socio-economic background.

1 2 3 4 5 n/a

15

14. demonstrated knowledge and understanding in the use of developmental school counseling

1 2 3 4 5 n/a

15. used technology effectively in the role of the counselor.

1 2 3 4 5 n/a

16. used appropriate assessment strategies

1 2 3 4 5 n/a

17. demonstrated the ability to be tactful.

1

2 3 4 5 n/a

18. effectively participated in conferences/staffings.

1 2 3 4 5 n/a

19. provided effective small group guidance.

1 2 3 4 5 n/a

20. provided effective individual counseling.

1 2 3 4 5 n/a

21. worked to create and maintain positive learning environments

1 2 3 4 5 n/a

22. drew from current and relevant resources when preparing guidance lessons.

1 2 3 4 5 n/a

23. showed the ability to function as a team member of a dept/school.

1 2 3 4 5 n/a

24. demonstrated the ability to use educational, vocational, personal/social information in assisting students with the skill of decision making.

1 2 3 4 5 n/a

25. followed ASCA & ACA ethical guidelines.

1 2 3 4 5 n/a

26. demonstrates pro active strategies toward problems.

1 2 3 4 5 n/a

27. demonstrates sensitivity to cultural, gender and socioeconomic differences.

1 2 3 4 5 n/a

Supervisor comments: Please include positive personal characteristics and professional skills as well as any recommendations that will assist the student. Include strengths and areas of growth as well as areas in need of growth.

Student Signature: ____________________________ Date: ________________ Supervisor Signature: __________________________ Date: ________________

Student Comments:

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University of Arizona, College of Education Educational Psychology Department

School Counseling Program Internship EDP 593b

School Site Supervisor Evaluation of Student Performance

Date: Name of Student: Site Supervisor: School: Please rate the intern on the following scale:

Unacceptable Marginally Acceptable

Acceptable Good Superior N/A

1 2 3 4 5

The intern … 1. was receptive to constructive feedback.

1

2 3 4 5

N/A

2. was dependable and reliable 1

2 3 4 5 N/A

3. communicated about absence/tardiness.

1

2 3 4 5 N/A

4. was able to function without close supervision.

1 2 3 4 5 N/A

5. demonstrated professionalism in attire/appearance.

1 2 3 4 5 N/A

6. developed positive relationships w/other staff members.

1 2 3 4 5 N/A

7. exhibited developmentally appropriate counseling skills.

1 2 3 4 5 N/A

8. was flexible and able to meet the needs of the worksite.

1 2 3 4 5 N/A

9. showed growth and increasing independence

1 2 3 4 5 N/A

10. strived to gain increasing skills and knowledge.

1 2 3 4 5 N/A

11. demonstrated exemplary ethical behaviors.

1 2 3 4 5 N/A

12. completes total number of hrs/days in a timely manner.

1 2 3 4 5 N/A

13. used teaching and learning strategies that reflected sensitivity to students’ cultures, learning styles, special needs and socio-economic background.

1 2 3 4 5 N/A

14. demonstrated knowledge and understanding in the use of developmental school counseling

1 2 3 4 5 N/A

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15. used technology effectively in the role of the counselor.

1 2 3 4 5 N/A

16. used appropriate assessment strategies

1 2 3 4 5 N/A

17. demonstrated the ability to be tactful.

1

2 3 4 5 N/A

18. effectively participated in conferences/staffings.

1 2 3 4 5 N/A

19. provided effective small group guidance.

1 2 3 4 5 N/A

20. provided effective individual counseling.

1 2 3 4 5 N/A

21. worked to create and maintain positive learning environments

1 2 3 4 5 N/A

22. drew from current and relevant resources when preparing guidance lessons.

1 2 3 4 5 N/A

23. showed the ability to function as a team member of a dept/school.

1 2 3 4 5 N/A

24. demonstrated the ability to use educational, vocational, personal/social information in assisting students with the skill of decision making.

1 2 3 4 5 N/A

25. followed ASCA & ACA ethical guidelines.

1 2 3 4 5 N/A

26. demonstrates pro active strategies toward problems.

1 2 3 4 5 N/A

27. demonstrates sensitivity to cultural, gender and socioeconomic differences.

1 2 3 4 5 N/A

28. meets responsibilities such as being on time, keeping appointments, providing materials and other assistance in a reliable and dependable manner.

1

2 3 4 5 NA

29. follows the policies and procedures of the cooperating school district.

1

2 3 4 5 NA

30. cooperates with peers. 1

2 3 4 5 NA

31. cooperates with site supervisor. 1

2 3 4 5 NA

32. shows awareness of and respect for teacher time in planning.

1 2 3 4 5 NA

33. consults with teachers in planning classroom guidance activities.

1 2 3 4 5 NA

34. demonstrates professional behavior while at the internship site.

1 2 3 4 5 NA

35. provides counseling tapes that are of good technical quality.

1 2 3 4 5 NA

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36. provides written materials that reflect knowledge of the rules of spelling, grammar, syntax, organization and neatness.

1 2 3 4 5 NA

37. responds to students on site in an empathetic and nonjudgmental manner.

1 2 3 4 5 NA

38. uses a variety of techniques and strategies appropriately.

1 2 3 4 5 NA

39. demonstrates enthusiasm for developmental school counseling.

1 2 3 4 5 NA

40. takes initiative in the development of appropriate activities or tasks.

1 2 3 4 5 NA

41. relates appropriately to students. 1

2 3 4 5 NA

42. demonstrates insights into own assets and challenges.

1 2 3 4 5 NA

43. assists students in the transition to the next grade and/or educational level.

1

2 3 4 5 NA

44. informs administrators, teachers, students and parents about the system delivery and comprehensive nature of a developmental counseling program.

1 2 3 4 5 NA

45. provides individual and group counseling to students to meet their remedial, preventive and developmental needs.

1 2 3 4 5 NA

46. assists students with educational and career decision-making through individual and group counseling and guidance.

1 2 3 4 5 NA

47. provides consultation to teachers with special emphasis on helping students with developmental needs, behavioral assessment and classroom management.

1 2 3 4 5 NA

48. consults with parents regarding the students’ academic and social development.

1 2 3 4 5 NA

The University Supervisor has discussed this instrument with me. Student Signature: Date: Supervisor Signature: Date: Student comments (use back if more space needed):

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University of Arizona, College of Education Department of Educational Psychology

School Counseling Program Internship and Practicum

School Site Visitation Form Date: ______________________ Name of Student: _________________________________ School Site: _____________________________________ Comments of and Observations of University Supervisor: Signature of Site Supervisor: __________________________________________ Signature of University Supervisor: _____________________________________ Signature of Student: ________________________________________________ Date: ____________________

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School Counseling Practicum Internship Site Evaluation Form (To be completed by the counseling student)

School Date Address Name of the intern completing evaluation

Please rate on the following scale:

Unacceptable Marginally Acceptable

Acceptable Good Superior

1 2 3 4 5

Orientation to site I was given an orientation to the school site. 1 2 3 4 5 I was able to get involved right away. 1 2 3 4 5 I was given additional orientation as needed. 1 2 3 4 5 Professional treatment I was treated as a professional. 1 2 3 4 5 I was included in activities. 1 2 3 4 5 I was treated with respect as a peer. 1 2 3 4 5 I was welcomed by all staff. 1 2 3 4 5 Quality of supervision Supervision was regularly scheduled. 1 2 3 4 5 Supervision was helpful. 1 2 3 4 5 Supervision was geared to my level of training. 1 2 3 4 5 My supervisor was supportive. 1 2 3 4 5 Experiences I learned the overall school operation. 1 2 3 4 5 I had access to students. 1 2 3 4 5 I had appropriately challenging duties. 1 2 3 4 5 I felt I made a contribution to the program. 1 2 3 4 5 Overall evaluation I learned a great deal at this school. 1 2 3 4 5 I felt prepared for assignments at this school. 1 2 3 4 5 I would recommend this school for internship. 1 2 3 4 5 Name the supervisor(s) you would recommend at this school: Other comments/recommendations/cautions:

Supervisor’s Name Date Signature Date

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University of Arizona, College of Education Educational Psychology Department

School Counseling Program School Counseling Internship University Supervisor Evaluation Form

(To be completed by student at end of semester) Please rate on the following scale:

Unacceptable Marginally

Acceptable Acceptable Good Superior N/A

1 2 3 4 5 N/A The University Supervisor: 1. promoted growth in my interests,

abilities and learning. 1 2 3 4 5 N/A

2. arranged for relevant speakers at seminar meetings.

1 2 3 4 5 N/A

3. was very professional in dealings with me.

1 2 3 4 5 N/A

4. assisted in the selection of an appropriate school site.

1 2 3 4 5 N/A

5. made helpful suggestions following an observation.

1 2 3 4 5 N/A

6. spent adequate time in observations and consultations.

1 2 3 4 5 N/A

7. accepted and respected me as a person.

1 2 3 4 5 N/A

8. recognized and encouraged further development of my strengths and capabilities.

1 2 3 4 5 N/A

9. encouraged and listened to my ideas and suggestions for developing my counseling skills and provided suggestions.

1 2 3 4 5 N/A

10. encouraged me to use new and different techniques when appropriate.

1 2 3 4 5 N/A

11. allowed me to discuss problems I encountered during the field experience.

1 2 3 4 5 N/A

12. maintained a supportive supervisory setting.

1

2 3 4 5 N/A

13. responded promptly to my emails or phone calls.

1 2 3 4 5 N/A

14. had fair and challenging requirements.

1 2 3 4 5 N/A

15. was respectful of cultural, intellectual and ethnic diversity.

1 2 3 4 5 N/A

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16. effectively served as a liaison between the university and school counseling program and the school site.

1 2 3 4 5 N/A

17. I would rate my university supervisory experience as …

1 2 3 4 5 N/A

Major strengths of university supervisor:

Areas to refine:

Additional comments:

Student Signature (optional) Date

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University of Arizona Department of Educational Psychology

School Counseling Program

Student in School Audiotape/Videotape Consent Form

I, the undersigned, do hereby consent to the recording of my voice and/or image (or that of my

minor child) by _________________________________, acting under the authority of The

University of Arizona. I understand that the material being recorded Is available only for

educational and supervisory purposes, and I do hereby consent to such use.

I release The University of Arizona and its undersigned representative, acting under the authority

of The University of Arizona, from any and all claims arising out of such taping and recording

for supervision purposes only, as is authorized by The University of Arizona.

I understand that I may revoke my consent at any time except to the extent that action has been

taken thereon.

This release will expire on or before ____________________________. ____________________________________________________ __________________ Signature of Participant/Student Date __________________________________________________ __________________ Signature of Guardian or Nearest Relative Date ___________________________________________________ __________________ Signature of Intern/Practicum Student Date ___________________________________________________ __________________ Signature of Site Supervisor Date

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La Universidad de Arizona Programa Consejeria de Escuela

Consentimiento para Filmar en Video o Audio

Yo, la persona que firma abajo, voluntariamente doy mi consentimiento para que

____________________________________________ grabe y/o filme mi vox y/o imagen (o la

de mi hijo menor de edad), actuando bajo la autoridad de la Universidad de Arizona. Yo

entiendo que el material que será grabado estará disponible solamente con el propósito de

educación y supervisión, así yo voluntariamente doy permiso para ese uso.

Yo libero a Universidad de Arizona y a sus representantes, actuando bajo la autoridad de

Universidad de Arizona, de cualquier y todas las posibles demandas que podrían levantarse de

estas grabaciones que serán usadas con el propósito de supervisión solamente, como es

autorizado por Universidad de Arizona.

Yo entiendo que yo puedo retirar mi consentimiento en cualquier momento excepto si alguna

acción legal ha sido tomada.

Este consentimiento se caducaráel _________________________________ o antes. ___________________________________________ ___________________ Firma del Participante Fecha __________________________________________ ___________________ Firma del guardián o el pariente Fecha __________________________________________ ___________________ Firma del Consejero/Estudiante Fecha __________________________________________ ___________________ Firma del Consejero de la Escuela Fecha

25

Discrimination and Sexual Harassment A student who believes that he or she has experienced discrimination or sexual harassment should call the Affirmative Action Office at 621-9449. The student will be referred to an individual with expertise in these areas for confidential advice on handling the situation or filing a written complaint. Students with disabilities who would like information on University policies with regard to the Americans with Disabilities Act (ADA) should contact the Disabled Students Office. Students are also encouraged to access the Affirmative Action homepage for information on discrimination, including sexual harassment, and the ADA.

Graduate Student Grievances The University of Arizona’s graduate student grievance policy and procedures can be found at http://grad.arizona.edu/Catalog/Policies/Grievance_Policy.php