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AGNP Consent to Release Student Information to Affiliated Agencies

Student Consent Form

  • The College of Health Sciences (“COHS”) has entered into contracts with healthcare agencies (the “Affiliated Agencies”) in order to provide COHS students access to direct delivery of patient care or health care services through clinical experiences, research opportunities, and other experiences at or with Affiliated Agencies. By signing below, you acknowledge that COHS has a relationship with these Affiliated Agencies, including but not limited to any Affiliated Agency where you may be placed as part of your COHS program as well as any Affiliated Agency that may employ you during your enrollment in your applicable program, and consent to the sharing of information about you prior to, during, and subsequent to your placement with the Affiliated Agency, provided information is related to your placement at the Agency and/or your educational Program with COHS.

    COHS is required by contract to periodically supply Affiliated Agencies with certain information about students enrolled in a COHS program and placed at Affiliated Agencies, including proof of student compliance with health examinations and immunizations, drug testing and background check requirements prior to any clinical placement, as well as the results of such background checks and drug testing, all as may be required under the applicable contract. In addition, COHS has a duty to supply Affiliated Agencies with certain additional information about students placed at the Affiliated Agencies, including a student’s status in a COHS program, dismissal from a COHS program, completion of certain components of the program, as well as COHS or Boise State University’s knowledge of certain crimes charged or committed while a student is enrolled in a COHS program, or unethical behavior that may pose a risk to patients (as determined in the sole discretion of COHS) under the care of any student enrolled in a COHS program and placed at an Affiliated Agency. Affiliated Agencies, in turn, must supply COHS with information regarding student’s performance at the Affiliated Agency, including student’s attendance and performance at the Affiliated Agency, dismissal or requested dismissal and the reasons therefor, completion of certain components of the program, knowledge of certain crimes charged or committed while a student is placed at an Affiliated Agency, behavior that may pose a risk to patients (as determined in the sole discretion of Affiliated Agency) under the care of any student placed at an Affiliated Agency, among other similar information pertaining to a student’s placement with Affiliated Agency.

    I understand that any such information may be education records and I hereby permit Boise State University and the College of Health Sciences to release the information, including any education records of the types set forth above. I further authorize Affiliated Agency to share such information with Boise State University and the College of Health Sciences. I realize that such records may include and not be limited to academic, health and disciplinary records, identification photos, as well as my social security number for identification/security purposes. I understand this information may be released and viewed by Affiliated Agencies under contract with Boise State University and/or COHS, including any Affiliated Agencies where I may participate in a clinical or other experience, internship, or volunteer or employment experience, as well as employees or advisors of Boise State University. I am allowing this release of my education and other records for educational and professional purposes in order to prove my qualifications to enter into the applicable program or profession or for other valid educational purposes. The validity of this consent and release shall expire five years following my graduation, completion, or other separation from any COHS program.

    By signing below, I acknowledge to having completely read, fully understand the above statements and agree to be bound thereby.