Joyce Fowler, Ph.D., 415 N. McKinley, Ste. 500, Little Rock, AR 72205

CONSENT REGARDING EVALUATION SERVICES

PSYCHOLOGICAL/NEUROPSYCHOLOGICAL EVALUATION FOR AIR TRAFFIC CONTROLLERS

You have been referred for a psychological/neuropsychological evaluation by the Federal Aviation Administration (FAA). The FAA requires the completion of this evaluation to assist it in determining fitness for duty. The Fowler Institute has been engaged by the FAA to conduct this evaluation. The Fowler Institute does not have a doctor-patient, confidential or privileged relationship with you. The Fowler Institute will not be providing follow-up care or treatment for you. If any treatment is needed, information will be provided to you on how you may access appropriate care. The Fowler Institute will be objective and impartial. The original report will be sent to the FAA, and you will not be provided with a copy of the report.

What to expect: A psychological/neuropsychological evaluation includes a diagnostic and history taking interview, review of relevant records, collaborative interviews, and tests as set forth in the FAA’s specifications for evaluations. We will follow the specifications as set forth.

Confidentiality: The Fowler Institute will not discuss you or your evaluation by name except with FAA or their representatives. However, there are exceptions to this confidentiality. These exceptions include but are not limited to:

1)If you threaten to harm yourself or another person, The Fowler Institute may have a duty to contact the intended victim and law enforcement or other authorities.

2)If you tell The Fowler Institute about child or elder abuse or neglect, they may be required to inform certain officials and/or law enforcement officials.

3)The Fowler Institute may be required to release information about you if ordered to do so by a court of law, or if you enter into litigation and make your mental condition part of the case, or if you are applying for benefits or

4) As otherwise required by law.

Risks and likely benefits of participation:Psychological/neuropsychological evaluations often provide useful information about a person’s abilities, strengths and weaknesses in mental abilities, mood state, and personality. Competency relative to the job position is determined by the FAA, not evaluation results. However, our evaluators will attempt to make statements in your report about the absence or presence of psychological/neuropsychological problems that relate to stability and functional status as they relate to your job description. The process of evaluation is lengthy and can be tiring. It might be uncomfortable for you to reveal personal information or to receive feedback about your strengths and weaknesses. While evaluation results are often helpful in making a clinical diagnosis or a recommendation about your fitness, our evaluators cannot guarantee that he/she will be able to make a conclusive diagnosis or recommendation related to the concerns raised by the FAA. The Fowler Institute will make their best effort to help you be as comfortable as possible during the evaluation process. If problems arise, please bring those to their attention. If you become so tired that you prefer to finish on another day, please let The Fowler Institute evaluator know.

Voluntary nature of evaluation and Consent to Disclose Report: You agree to participate in this evaluation. Your participation in this evaluation is voluntary as far as The Fowler Institute is concerned, and The Fowler Institute staff will not prevent you from discontinuing the evaluation at any time. The Fowler Institute does not know what the consequences will be if you do not complete the exam, and you should consider these consequences. By signing this consent, you also are providing The Fowler Institute with permission to provide a copy of a report of the evaluation to the FAAand to discuss the results with the FAA as needed in addition to consulting psychologist for review as needed. The report will be sent regardless of how well you feel you performed on the exam. The information from this report will be only one part of the information that the FAA utilizes to make determinations regarding your FAA employment. All decision making regarding FAA employment is made by the FAA, not by our evaluators.

Effort: Testing requires your effort. The results will not be accurate if you do not give your best effort. Let The Fowler Institute staff know if anything prevents your best effort.

------

If you have any questions that are not answered by the above information or if anything above is not clear to you, please discuss it with The Fowler Institute staff before signing below. I, ______, understand the above information and agree to these terms for my evaluation, including release of evaluation data and report to the FAA/their designees.

Signature:______Date:______

Print name:______

Rev. 7/13/17