I give my permission for ___________________________, a student in Psy 442, to interview myself or a child for whom I am the legal guardian. I understand that the interview is for a senior level psychology class project and may be videotaped or audiotaped. I understand that this is not a therapy session but a chance for the student to develop interviewing skills. The class or the instructor may watch or listen to the tape as a means of learning about interviewing. Students in the class are expected to maintain the confidentiality of the interviewees but interviewees should be cautious in what they reveal. The interviewee may terminate the interview and have the tape erased by telling the interviewer at the time of the interview. The interviewee may refuse to answer any question or may provide false information. The interviewer's grade will not be harmed. Developing the interviewer's sensitivity to interviewee concerns is one of the course goals.
If an interviewee indicates dangerousness to self or others, for example, contemplating suicide, then the interviewee will be referred for assistance and the appropriate authorities will be notified.
I have read and understand the conditions of this interview
_________________________________
(Signature of Interviewee)
______________________
Phone Number
_____________
Date
________________________
Witness
The interviewee should remove the following portion and keep it.
If you have further questions regarding the interview for Psy 442 contact the course instructor: Dr. Sally Kuhlenschmidt, Dept of Psychology, WKU, Bowling Green, KY 42101. Phone 502-745-4417 or 502-745-6508 or the student who conducted the interview:
Name:____________________
Phone:___________________
Address:_____________________________________
Document created by Sally Kuhlenschmidt, June 1996
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