The Informed Consent Statement

When students login to ConexED, an Informed Consent Statement appears and must be agreed to
before the student can proceed.

What it is and Why it is Used

The Informed Consent Statement is a document that advises students about FERPA compliance, relevant policies, state and federal laws, and rights. Examples of rights and policies include potential confidentiality limits with video conferencing, the policy on using a webcam, permission for administrators to access recorded information for the purpose of improving the services, and the agreement to having the session recorded.

The Consent Statement for your institution or district can be added in the Admin Settings by the ConexED Administrator. The statement can be written in either plain text or html.

A Consent Statement can also be added in the group’s Login Settings. Adding a Consent Statement here will override the institution’s statement when students interact with just that group.

If you draft an original statement or use one of the examples provided in this resource as a template, it is a best practice to work with the legal team at your institution to finalize the language, so it is appropriate for your specific school and particular students.

Examples of Informed Consent Statements

Example 1

To [Name of School] students:

Please read the entire Informed Consent Statement below BEFORE using this system to access services. Please click on “I Agree” at the bottom if you wish to schedule an online appointment.

TERMS & CONDITIONS – Information about you is confidential. It is important that you supply the most current information about yourself, your educational history, plans, and career goals so that employees may provide you with the most accurate information specific to your needs.

  • Per the Family Educational Rights and Privacy Act (FERPA), I hereby grant permission for [Name of School] employees to share with me electronically any academic information about myself during an online appointment and/or workshop or group session, via the ConexED Meeting Center, which I understand to be encrypted and secured.
  • When interacting with the online system and [Name of School] personnel, I will authentically represent myself in all aspects.
  • I am the person who will be attending the online appointment and will provide accurate personal and academic information (such as educational history and goals) to [Name of School] personnel.
  • I authorize [Name of School] and its employees to record my online interaction sessions for the sole purpose of assisting me with my educational pursuits.
  • I give permission to [Name of School] personnel and ConexED Meeting server personnel (administrators) to, when necessary and for the sole purpose of improving the online meeting services, have access to recorded information from an online interaction between [Name of School] personnel and myself.
  • I understand that when using [Name of School]’s online services, I must protect my personal information from others, therefore:
    • I will provide my [Name of School] student email address (@apps.school.edu).
    • I understand that the online scheduling system will automatically email confirmation messages and notifications to the [Name of School] student email address.
    • I understand that if I choose to share my [Name of School] Student email account with another person, that person will have access to my Meeting ID# and password, which may allow that person eventual access to my personal and academic information.
    • If I choose to share my email account, I release [Name of School] from any liability resulting from such action.

[Name of School] is committed to protecting your privacy and personal information. By accepting these terms, you agree to this privacy policy and consent to the data practices described above.

Example 2

To all current and prospective [Name of School] students. Below are the terms and conditions for using the Online Counseling Services at [Name of School]. Please read carefully and click the agree button below in order to move forward with online counseling.

  • I agree to represent myself authentically in all aspects when participating in an online counseling session and/or online group workshop. I will provide accurate personal information, educational history, and information related to my educational and career goals so that online counselors can provide the most accurate information.
  • Per the Family Rights and Privacy Acts, I hereby grant permission for [Name of School] online counselors to discuss information related to my academic records during a live counseling appointment and/or group workshop, via the online Cranium Café meeting center, which I understand to be encrypted and secure. Although Cranium Café encrypts and secures all files using 256-bit SSL encryption, there is no assurance of confidentiality should the system be breached.
  • I grant permission for [Name of School] online counselors to record my live online counseling sessions and/or workshop for the sole purpose of assisting me in my academic pursuits.
  • I authorize [Name of School] counselors, relevant [Name of School] personnel, and Cranium Café administrators to, when necessary and for the sole purpose of improving the online meeting services, have access to recorded information from a live online counseling session and/or workshop between myself and a counselor.
  • I understand that when using [Name of School] Online Counseling Services, I must protect my personal information from others; therefore, if I choose to share my [Name of School] login credentials, I release the [Name of School] Counseling Office and the [Name of School] from any liability resulting from such action.

I have read the above information in detail. I understand and agree to the Terms and Conditions established for [Name of School] Online Counseling Services.

Example 3

[Name of School] University is committed to protecting your privacy and personal information. By accepting these terms, you express your intention to consent to this privacy policy and the terms outlined:

  • I grant permission to the [Name of School] University staff access to my personal information, including but not limited to my name, e-mail address, phone number, Student ID, academic program, courses enrolled, and other information needed to provide the appropriate academic support I need.
  • I grant permission to staff, tutors, writing consultants, and faculty I interact within a live online session to record the events I attend, as needed.
  • I grant permission to the release of information obtained in a session to be shared with my advisors and/or course professors whenever necessary to facilitate my academic success.

Example 4

To all current and prospective [Name of School] students, you must carefully read the entire “Terms & Conditions” and “Privacy Protection” statements below BEFORE using the [Name of School] appointment scheduling and online services. Be advised that by using the [Name of School] appointment scheduling and online services, you are confirming that you have read and agree to the “Terms & Conditions” and “Privacy Protection” statements.

Please take note that the Family Educational Rights and Privacy Act (FERPA) of 1974 is a federal law designed to protect the privacy aspects of a student’s educational record. It regulates the use and disclosure of personal information in educational records and permits a student to know what material is maintained in those records. For the purpose of providing in-person and online education and counseling services, student information will be collected and made available to school official(s) with legitimate educational interests, and student information may also be accessed by a ConexED technical administrator to facilitate your online education and counseling, with your consent. Please review the [Name of School] FERPA policy which can be found at this link: https://xxx

You can obtain more information about the Family Educational Rights and Privacy Act of 1974 through the U.S. Department of Education’s website: (https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html)

[Name of School] Policy XXX which governs Computer and Network Use may be found at this link: https://xxx

Please click the “agree” button below in order to move forward with requesting in-person and online services.

TERMS & CONDITIONS:

I affirm and acknowledge that I am a student enrolled at [Name of School] and I consent to the release of my education records to the counselors and staff employed by [Name of School District] ([Name of School]) for the purpose of providing online counseling services in connection with my academic program. I understand that education records include, but are not limited to, information about my academic standing, personally identifiable information, disciplinary issues, and financial obligations to [Name of School].

As used below, “I,” “you,” ”myself,” and other personal pronouns refer to the student. I agree to represent myself authentically in all aspects when participating in an in-person or online counseling session and/or student services or webinar.

  • I agree to the release of my educational records to [Name of School] counselors and/or support staff, which may include, but are not necessarily limited to, a learning disabilities specialist, interpreter, and or a learning assistance program technician if any when such support is necessary and, or requested by me.
  • I authorize the counselor and/or support staff to provide me with information related to my education records online through the use of educational websites and other resources.
  • I grant permission for [Name of School] online counselors and/or support staff to record my live online meeting sessions and/or webinar for the sole purpose of assisting me in my educational pursuits
  • I hereby grant permission for [Name of School] online counselors and/or support staff to discuss information in my education records with me during live online meeting sessions and/or webinars, which I understand to be encrypted and secure.
  • I authorize [Name of School] counselors and/or support staff, relevant personnel, and ConexED administrators to, when necessary and for the sole purpose of improving the online meeting services, have access to recorded information from a live online meeting session and/or webinar between myself and [Name of School] personnel.

PRIVACY PROTECTION:

[Name of School] is committed to protecting your privacy and personal information. No student education records or personally identifiable information is shared with outside entities, except those institutions to which you provide your information, or consent to have [Name of School] provide your information, including as specified in the Terms & Conditions above, and where required and/or authorized by law.

The online meeting sessions and/or webinars may be recorded.

Additionally, because of the real-time video and audio interactions that will be used for online meeting sessions and/or webinars, you should be aware that when you are logged onto the [Name of School] appointment scheduling and online services, depending on the placement, positioning, and angle of your communication device, [Name of School] online counselors and/or support staff likely will be able to view the area behind and around you, which may include areas of your home/location and other people and/or activities within the home/location. Additionally, for these same reasons, [Name of School] online counselors and/or support staff may also be able to hear what is going on in your surroundings. Thus [Name of School] cannot ensure and you should not expect either the confidentiality or privacy of any activities in your home/location during an online session.

When reviewing the Intake Form, please verify that the information about yourself, your educational history, academic plans and career goals is correct so that the counselor and/or support staff may provide you with the most accurate information specific to your educational objectives.

By clicking the “agree” button, I consent to the “Terms & Conditions” and “Privacy Protection” policy as described above.

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