Audiovisual Consent Form

Purpose: I hereby authorize my participation in practical exams, demonstrations, and/or studies to be recorded or filmed by audio and/or video equipment. The recordings will serve for Student performance assessment, classroom assignments, and instruction within the Penn State Hazleton Physical Therapist Assistant Program.

Procedures:

• Videotaping
• Audio taping
• Photographing students involved in a group will not be permitted to distribute such recordings to others outside of the group unless all members are in agreement.

Agreement: I agree to participate in demonstrations and studies conducted by my instructor/peers enrolled at Penn State Hazleton. I authorize that I may be the subject of audio and visual recordings associated with demonstrations and studies. Equipment for recording will be fully exposed and may include photography, audio recording, and audiovisual recording.

Storage and Distribution: Recordings will be stored in the Physical Therapy department on an electronic portfolio and may be held for future instructional purposes. They will not be distributed or published beyond the classroom unless permission is given from the individuals involved.

Access: Access to the recordings will include the instructor of the course, peers, and individuals of the group involved.

By signing below, I acknowledge that I have read and understood the terms of this consent form and agree to its conditions.

[Student Signature] _______________________ [Printed Name] ____________________

[Date] ___________________________