Overview of Evaluation:
The agency that referred you to The Center for Resilience & Wellness, LLC for assessment (hereinafter referred to as “the employer”) has requested a psychological fitness for duty evaluation to determine your ability to maintain or return to unrestricted work duties. Dr. Jennifer Webb and Dr. Nicolette Howells Cutright are the Licensed Psychologists who will conduct the psychological evaluation and administer the testing. The assessment will consist of standardized computer administered psychological testing, an oral interview, and a review of collateral or third-party information made available by the employer or by you.
The assessment also will include a review of prior assessments if Dr. Webb, Dr. Howells Cutright, or another clinician previously evaluated you. Both the written inquiries and interview will probe public and private aspects of your life. These inquiries are necessary to adequately assess whether your current psychological functioning is sufficient to perform the requirements of your position. If at any time you wish to ask about the relevance of any question asked in the interview please ask, and you will receive an explanation as to why the requested information is needed. You have the right to terminate the assessment at any time.
Limits of Confidentiality:
Although the employer is the psychologist’s client, not you, the psychologist nevertheless will be mindful of her duty to conduct the evaluation with fairness and objectivity. You specifically understand and agree that you are not receiving treatment or health care from the psychologist and that the psychologist does not consider herself to be treating you. You understand that you are not being examined for any purpose relating to your personal treatment or to your personal health care. Because the psychologist is conducting this evaluation at the request of the employer and for reasons having nothing to do with treatment or health care, you do not have doctor-patient or psychotherapist-patient privilege in your communications with her. Therefore, you understand and agree that anything you say or do during or in connection with the evaluation is entitled to disclosure, if relevant to the evaluation, and may or will be disclosed to others involved in the selection process who have a need to know it. The employer requires a report of pertinent findings and conclusions, including a determination of your psychological fitness for this position, following the completion of the assessment.
The employer may authorize release of the records associated with this assessment, including any written report, to any other qualified professional. Circumstances leading to such an authorization may include a mandatory fitness-for-duty evaluation, pre-employment psychological testing, disability claim, or other medical evaluation. State law also may require disclosure of otherwise confidential information for reasons associated with, but not limited to, risk of child abuse, a threat of serious harm to yourself or others, or court order.
Report of Findings and Conclusions:
Following the completion of the examination, the psychologist will give the employer an oral and written report of relevant findings and conclusions relating to their opinion about your psychological fitness to perform the duties of the position, pursuant to the attached authorization. These reports are necessary to fulfill the purpose for which you have been referred. The reports necessarily will contain private information, but the psychologist will make a good-faith effort to restrict the disclosure of private information to the minimum necessary to satisfy the purpose of the examination and to support her findings, conclusions, and recommendations. If the findings, conclusions, opinions, or recommendations are challenged in an adjudicative forum, the psychologist may make full disclosure of all information as may be necessary or required by law.
Waiver of Access to Report and Records:
This assessment is conducted solely to aid the employer in determining your ability to perform the required duties. You will not be provided a copy of any report the psychologist provides the employer concerning your level of psychological fitness. Because the employer is the client, your authorization will not permit the psychologist to release or disclose the report to you or any third party. You specifically waive any and all statutory rights to access and review personal health care or any other information as it pertains to this examination, if any, whether arising under state or federal statutory, regulatory or common law, including but not limited to, the Health Insurance Portability and Accountability Act of 1996, and therefore have no rights to access or review the notes, reports, tests, analyses or other information generated in connection with this evaluation of your psychological fitness. Even if some of the information contained or produced in this assessment might otherwise be accessible to you, this information is inextricably interwoven with other confidential data to which you otherwise would not be entitled. Therefore, you agree to exonerate, release, and discharge The Center for Resilience & Wellness, LLC and the employer, its officers, agents, or assigns, from any claim or damages, whether in law or in equity, on behalf of yourself, your heirs, agents, or assigns, for their refusal to make available any and all information contained in this psychological fitness for duty evaluation other than the final determination.
Payment for Services:
The employer is compensating the psychologist for service. However, the psychologist will remain objective and neutral. As such, she will have sole control over the examination and their resulting opinions, conclusions, and recommendations.
Potential Outcomes and Uses of the Examination Results:
As a result of this examination, the psychologist may conclude that you are (1) psychologically fit for duty or (2) psychologically not fit for duty. The employer has determined the standards and degree of suitability it requires for qualification. Regardless of the conclusions reached and communicated in the report, the employer may choose not to rely on the findings and recommendation, in whole or in part, when deciding on your status. Alternatively, your employer may rely entirely on the report. Thus, depending on the ultimate conclusions and recommendations concerning your psychological fitness, and depending on the employer’s consideration of the conclusions and recommendations, the results of this examination may have a significant impact on your job.
The psychologist’s opinion concerning your psychological fitness for this position is NOT a statement or opinion about your suitability for a different position. Rather, it is a statement only about the degree to which the full range of assessment information available to the psychologist provides evidence at this time of the psychological fitness necesaary to perform the duties of your current position.
Regarding Your Freedom to Decline to Participate:
You are free to decline participation in this examination. However, your decision not to participate in the examination will result in further action by your employer regarding your ability to fulfill your duties.
Redisclosure:
The psychologist will advise the employer to maintain the written report in a confidential medical file separate from other personnel information and that the information should be made available only to persons who have a bonafide need to know the information included in the report. Nevertheless, by signing the authorization attached hereto and authorizing the psychologist to release this information to the employer, there is the possibility that the employer could redisclose this information. By signing the authorization, you will expressly release The Center for Resilience & Wellness, LLC , from any liability for the disclosure.
Genetic Information:
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA, Title II, from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to any request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assertive reproductive services.
Recording and/or Photographing During the Evaluation:
You are not authorized or permitted to photocopy, photograph, record or capture any portion of the evaluation, in whole or in part, including but not limited to computerized testing, personal history questionnaires, oral interview, and conversations with Dr. Jennifer Webb and Dr. Nicolette Howells Cutright whether in-person or by telephone. This prohibition applies to all forms of recording, whether digital or analogue. By agreeing to proceed with this examination, you agree to accept this prohibition and any civil and/or criminal consequences for violating it.
Authorization to Use and Disclose Protected Health Information:
I authorize The Center for Resilience & Wellness, LLC to use and disclose their findings and opinions concerning my past, present or future physical or mental health or condition, as well as their conclusions, opinions, and recommendations as to my psychological fitness for duty to the agency that referred me for this examination (hereinafter referred to as the “employer”). This authorization does not authorize any of my prior or current health care providers to disclose personal health care records to The Center for Resilience & Wellness, LLC or my prospective employer without separate and specific written authorization, except as permitted by law.
I understand that the psychologist will make a good-faith effort to restrict the disclosure of private information to the minimum necessary to satisfy the purpose of the examination and to support the findings, conclusions, and recommendations. Consistent with the provisions of state and federal law, I understand that the employer will be advised to maintain any written report provided to it by the psychologist in a confidential medical file separate from other personnel information and that the information should be made available only to persons who have a bona fide need to know the information included in the report. I have been informed that I will not receive a copy of the written report, nor will I be able to authorize its release to any other person or party. I specifically waive any statutory rights to access and review personal health care information as it pertains to this examination.
I acknowledge that the psychologist has no control over how the employer uses the report once it receives it. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer protected under federal law. I expressly release The Center for Resilience & Wellness, LLC from liability for that redisclosure. However, I also understand that federal or state law may restrict redisclosure of mental health information and drug/alcohol diagnosis, treatment or referral information.