Page 70 - JSOM Winter 2019

APPENDIX A APPENDIX B

PEAC Program Limits of Confidentiality Form PEAC Questionnaire

NAME (Last, First, MI): ____________________________ NAME (Last, First, MI): ____________________________
Last 4 SSN: ___________________ Last 4 SSN: ___________________
Today’s Date: _________________
1) Limits of Confidentiality of Psychological Assessment
Information Age: ___________ DOB: ___________
Access to this information is confidential and will only
be viewed by those involved in the assessment. There are, Rank: _______________ Current MOS: ________________
however, limits to the confidentiality of the psychological
assessment information.
Native Language: English _____ Spanish _____
Examples of these limits to confidentiality are as follows:
Other ___________________________
1. If we believe you intend to harm yourself, or someone
else, it is our ethical and professional duty to inform Race/Ethnicity:
others.
2. In instances of suspected child or spouse abuse, we are Asian _____ Black _____ Hispanic _____
required to report this to the appropriate authorities. Native American _____ White _____
3. Demographic and relevant information that has had
your personally identifiable information removed Other ___________________________
may be utilized for research and process improvement
initiatives. GT Score (if applicable): __________
2) Privacy Act Statement – Psychology Assessment Total years of completed education: __________
and Selection Records (12= High School graduate; 16=Bachelors)
Authority for collection of information including Social
Security Number (SSN): Sections 133, 1071-87, 3012, Please answer the following questions:
5031, and 8012, title 10 United States Code and Executive 1. What do you want to learn from this assessment?
Order 9397. In accordance with the Privacy Act of 1974,
the personal information obtained will facilitate and doc-
ument your psychological assessment. Your partial Social
Security Number is required to identify and retrieve your 2. What aspects of your life would you most like to
records. Disclosure is entirely voluntary. Your signature improve?
below merely acknowledges that you have been advised of
the foregoing. If requested, a copy of this form will be fur-
nished to you. 3. What do you see as your biggest interpersonal
challenges?
3) Request for Psychological Testing, Evaluation,
and Coaching: PEAC
1. I, the undersigned, request and consent to psychological
testing, evaluation, and coaching. 4. What do you see as your biggest occupational
2. This request for psychological testing, evaluation, and challenges?
coaching is voluntary. No one has forced or coerced me
to consent to psychological testing and evaluation.
3. I further understand that my name and partial Social 5. What aspects of your personality make you
Security number will be used to identify my assessment
file. The only people that will see my assessment file are successful?
the Operational Psychologist and NCOIC.
4. I have read and understand the limits of confidentiality
of psychological assessment information.
5. I understand that my assessment data will be kept in a
secured area.
By signing below you acknowledge that you: 1) have been
advised of the limits of confidentiality, 2) been advised of and begin to explore how their pattern of traits affects their
the purpose of collecting your social security number (Pri-
vacy Act), and 3) voluntarily request and consent to psy- performance.
chological testing, evaluation, and coaching.
Before the feedback session, the OPC prepares a document
that visually represents the Soldier’s assessment scores in com-
Signature parison with their peers (Appendix C). During the feedback
session, the OPC gives the Soldier a copy of the feedback
document so the Soldier can take notes on it. This approach
Printed Name and Rank
allows Soldiers to visualize their results, listen to the OPC’s
Last 4 SSN: ___________________ interpretations, and write down insights or key “take-home”
messages. This multisensory approach enhances learning by

68 | JSOM Volume 19, Edition 4 / Winter 2019