This form must be reviewed and signed by the CPE student prior to formal admission to an ACPE accredited CPE program and at the start of each subsequent unit in which the student enrolls.

CPE students shall be informed prior to acceptance into the program, as well as at the start of each subsequent unit, that their clinical materials and recorded and/or live observation media that are pertinent to the certification processes for Certified Educator Candidates or Associate ACPE Certified Educators, that are pertinent to the peer review process for ACPE Certified Educators, that are pertinent to a center’s accreditation process, or that are pertinent to ACPE approved research studies, may be used from the unit. All identifying information shall be redacted from written documents. A copy of this signed agreement shall remain a part of the center’s files indefinitely. Materials that are not supported with this signed Consent Form MAY NOT BE USED.

By signing below I understand that Certified Educator Candidate/Associate ACPE Certified Educator/ACPE Certified Educator will use my written evaluation, the above-named educator’s written evaluation of me, and other clinical materials pertinent to the above-named educator’s process toward certification as an ACPE Certified Educator or as part of the above-named educator’s peer review process, and I understand that such materials will have personal information redacted. I understand that the above-named educator will use recorded and/or live observation media that are pertinent to the above-named educator’s process toward certification as an ACPE Certified Educator or as part of the above-named educator’s peer review process, and I understand that such media may identify me. I understand that this use is for the purpose of the above-named educator’s professional development, certification, and/or peer review. I understand that my written materials and live/recorded observation media that may identify me may be read, heard, viewed, and discussed by the above-named educator’s professional colleagues as they assess the above-named educator’s professional development and competence as an ACPE Certified Educator. I understand that my clinical materials may be utilized by my center as data for demonstrating compliance with ACPE Standards for accreditation and/or for ACPE approved research studies without further notification to me.

My signature grants consent to all of the above.

I understand that I may revoke this authorization, in writing, to the above-named individual, and that if I choose to do this, I will no longer be able to participate in the unit of CPE and will not receive credit for the unit. Any clinical materials and/or live/recorded observation media obtained prior to the revocation of this authorization may still be used by the above-named educator.