Sample Informed Consent to return to In-person work

Informed Consent Template for

Return to Voluntary In-Person and/or On-Site Clinical Externship

            Externships, in which graduate students in health service psychology provide supervised clinical services to patients, are a central component of clinical training and an important mechanism for the development of profession wide competencies in clinical psychology.  Development of such competencies via provision of telehealth and tele-supervision is possible in many cases, but is not possible in all cases.  As many externship sites move toward at least partial re-opening, trainees must weigh the potential risks and benefits of returning to in person work. Such return to in-person work is voluntary and no student shall be penalized for deciding to withdraw from a clinical training position that necessitates a return to in-person work, or for opting to continue remote provision of services if a site allows a return to in-person work. 

There are risks associated with in-person onboarding procedures and with providing in-person clinical services (and/or onsite telehealth) for program-approved practica (also known as externships) during the COVID-19 epidemic.  These risks include potentially increased exposure to individuals who may be infectious.  While steps can and should be taken to mitigate that risk (use of adequate Personal Protective Equipment, social distancing when possible, limited time in small, enclosed spaces with other individuals, symptom checks of visitors, including patients, disinfection protocols for shared spaces) none of these strategies can eliminate the risk of infection.  You might become ill yourself, or you might unwittingly become an asymptomatic carrier and transmit COVID-19 to other people you interact with, including family and friends. 

You are strongly encouraged to consult with a health care provider of your own choosing regarding your individual risk factors to determine whether it is unwise for you to participate in in-person work at this time. 

It is the responsibility of the training site (whether an in-house clinic or an externship) to provide you with information relating to their safety protocols, and you should be informed of these protocols by the site prior to beginning any onsite activity at your externship. It is also the responsibility of the training site to provide adequate PPE, office space and protocols to reduce the risk of exposure to trainees, staff and patients. 

You are also advised to consider the risks of not returning to in-person work.  In some cases, this may mean that you will have to delay the acquisition of particular competencies, and may be slowed down in accruing hours towards internship application.  This may delay your application to internship and to graduation, which may have personal and financial consequences.  Should you decide not to return to in-person work at this time, or to withdraw at a later time, you are strongly encouraged to discuss academic, funding and training alternatives with your Director of Clinical Training, your advisor and your Director of Graduate Studies. 

By signing below, you acknowledge that you are aware of the risks and benefits of returning to provision of in-person and/or on-site telehealth work, and that your participation in the externship at this time is voluntary. 


Student Signature                                                                                 Date


Printed Name                                                                            Externship Site Name