Non-Disclosure and Consent Form

Thank you for participating in our study. Please be aware that confidential information may be disclosed to you and that you must not reveal information that you learn during the course of your participation. In addition, your session will be videotaped, to allow others who are not present to observe your session and benefit from your feedback.

Please read the statements below and sign where indicated. Thank you.

I agree that I will disclose no information about the study.

I understand that video and audio recordings will be made of my session. I grant permission to use these recordings for teaching purposes.

Date:
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Name:
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Signature:
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