ࡱ> HKG .bjbjAA 4J#y#y&~84<SRRRRR---,5-----[RR [[[-XRR[-[[۔n#0Su [u [---[---Su --------- \:   Appendix A Use of Video Capture in the Classroom: Informed Consent for guests or students who have not been admitted to a CHHS program _______________________________________ will be utilizing the video capture technology in (Instructors Name) ____________________________________ during the ________________________ semester. (Course Name & Number) (DATE) The recordings from this class (e.g. faculty lectures, class activities, student presentations) may be used for assessment, educational, or research purposes. (e.g. Content may be posted online for use in web-based or hybrid courses, used to assess the instructor or student skills, or shared in professional venues.) The University may use the recordings for other professional purposes including but not limited to: program assessment, fundraising, advertising, 91ȱ web sites, podcasting, research or any other purpose on behalf of the College of Health and Human Sciences or Western Carolina University. I understand that the recordings belong to the University, and I will not receive payment or any other compensation in connection with the pictures and recordings. I hereby release Western Carolina University and its successors and assignees from any liability by virtue of my photograph or videotape. I UNDERSTAND THE PURPOSE AND INTENT OF THE VIDEO CAPUTURE SYSTEM. I GIVE MY CONSENT FOR MY IMAGE/RECORDING TO BE USED AS DESCRIBED ABOVE. Name_______________________________ 92#_________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ Name_______________________________ 92#_________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ Appendix B Guest Speaker Informed Consent I hereby grant permission for Western Carolina University College of Health and Human Sciences to record my presentation by videotape, audiotape, digital means, or otherwise. I affirm that the presentation is my original work, that I am the legal owner of the presentation and therefore I have authority to sign this Consent Form. This recording is being made by 91ȱ for educational purposes, to promote broader understanding of the presentation content and subject matter, and will not be used for commercial purposes. I grant permission to 91ȱ to (check items you grant permission for): _____ Rebroadcast this presentation on 91ȱs closed circuit campus television system. _____ Show this presentation in public performance on campus. _____ Use all or part of this presentation in podcasts originating from the College, which may be available to the public. _____ Use all or part of this presentation in the creation of derivative works that could be posted on YouTube, Facebook, iTunesU, or other open web sites. _____ Incorporate all or any portion of the recording in derivative works or compilations in any form or media in connection with 91ȱs publications and/or public relations media. _____ Catalog and circulate the recording in accord with the 91ȱ Librarys cataloging and circulation policies. _____ Duplicate the recording for the purpose of preserving it, or replacing a damaged version. _____ Duplicate the recording for educational purposes. I understand that I am not entitled to receive any compensation for the recording or the Colleges use thereof, as described above, and that the recording may be archived for future use. I hereby release Western Carolina University and its successors and assignees from any liability by virtue of my photograph or videotape. ____________________________________________ Printed Name ____________________________________________ ________________________ Presentation Title Presentation Date ____________________________________________ ________________________ Signature Todays Date Appendix C Use of Video Capture: Informed Consent for students who have been admitted to a CHHS program All students admitted to ________________________(PROGRAM) must participate in classes and/or practical exams that will routinely be recorded. The recordings may also be used for additional educational or research purposes. (e.g. Content may be posted online for use in web-based or hybrid courses, used to assess the instructor or student skills, or shared in professional venues.) The University may use them for other professional purposes including but not limited to: program assessment, fundraising, advertising, 91ȱ web sites, or any other purpose on behalf of the College of Health and Human Sciences or Western Carolina University. I understand the purpose and intended use of the video capture as described above. I understand that the recordings belong to the University, and I will not receive payment or any other compensation in connection with the pictures and recordings. I hereby release Western Carolina University and its successors and assignees from any liability by virtue of my photograph or videotape. I UNDERSTAND THE PURPOSE AND INTENT OF THE VIDEO CAPUTURE SYSTEM. I GIVE MY CONSENT FOR MY IMAGE/RECORDING TO BE USED AS DESCRIBED ABOVE. _______________________________ _______________ ________________________ STUDENT SIGNATURE 92# DATE ____________________________________________ ______________________________ PROGRAM DIRECTOR SIGNATURE DATE Appendix D Video Capture in 91ȱ Speech and Hearing Clinic Informed Consent Permission for Clinical Service Re:________________________________________ DOB: ______/______/______ I understand that the Speech and Hearing Clinic at Western Carolina University is both a teaching and service center. It serves the training needs of students preparing for careers in Speech-Language Pathology and provides diagnostic and remedial services to persons with speech, language or hearing disorders. I understand that the clinical treatment carried out by student clinicians requires regular observation and/or participation by clinical supervisors. I also realize that the use of audio and video recordings is valuable in the professional training of speech-language pathologists and audiologists. Patient interactions with the clinicians/students will be captured on video. The videos will be used for educational, teaching, and research purposes. Therefore, I give my permission for evaluation and/or clinical treatment and for observation of my diagnostic and/or therapy sessions by clinical personnel and others approved by the clinical supervisor, as long as (I am/my child) is receiving services at this clinic. In the unlikely event that emergency medical attention is needed (in the absence of legal guardian or incapacitation of the client), I give permission for such medical attention to be obtained. I am also willing to permit audio and/or video taping to be used for education purposes (e.g., classroom instruction, workshops, and other research participation). I hereby release Western Carolina University and its successors and assignees from any liability by virtue of my photograph or videotape. _________________________ ___________________________ Witness Client, Parent, or Legal Guardian _________________________ ___________________________ Date Date     Western Carolina University [Type the document title] [Type the date] Consent form for video December, 2012   BGQcf  ! N P  B C Q j ? 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