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English 1103, The Human Experience



R. Andrew Brown, Instructor

Profile/Practicum Confidentiality Statement and Student Policy Contract
As a student at the University of North Carolina at Charlotte, enrolled in English 1103, Accelerated
College Writing and Rhetoric, I, the undersigned, realize that I have to find and achieve approved
placement for myself, and complete a miniature practicum called The Human Experience. I will abide by
all rules and guidelines established by the course instructor (R. Andrew Brown); I will also abide by all
rules and guidelines established by either my profile subject, person or place; all appropriate parties
indicate acceptance by signing below. By signing this statement, I agree to these terms and accept
the task of completing the practicum and associated assignments (field notes/blog entries, formal
and informal course work) to the best of my abilities.
I, the undersigned, pledge to keep all specifics regarding individuals, their cases, and sensitive materials
confidential. I will not discuss these matters with anyone outside my peer response group and the course
instructor, and all class work assigned in relation to this practicum (The Human Experience) will deal with
individuals only when they have agreed, explicitly, to be singularly identified. To do this, I must procure
the individuals written permission with signature and date to accompany my works. Otherwise,
the individual falls under the next category, following.
Those individuals who do not agree, explicitly, in written form with signature and date, must be excluded
from my written materials, including blog reflections and formal assignments, save by anonymous
representations. I will not and cannot discuss situations and context regarding these individuals using
identifying materials, save for my peer response group and instructor. If necessary for the integrity of my
works context and content, I will change their names and specifics to protect their privacy and my
professional credibility.
Furthermore, if I am revealed to have breached this confidentiality, which takes the form of a binding legal
and academic contract, then I forfeit the remainder of my practicum at this location, requiring me to start
anew with a new profile subject, beginning my academic field work and written components anew. More
so, I must draft a written appeal to my English 1103 instructor (R. Andrew Brown) to retain my current
grade-evaluation status. Failure to do so indicates that I have willingly accepted forfeiture of my grade for
this portion of the course, and most likely, will fail the term because of such. Written appeal will take the
form of a standard proposal, not more than one page, containing the information as to why the infraction
was accidental, how it will be rectified, and why course evaluation should not be discontinued.
If my profile subject deems that I have violated this confidentiality statement, he/she must notify me
immediately (if applicable), and then, jointly, we will notify the course instructor (R. Andrew Brown),
determining the best course of action to take together. Furthermore, if my profile subject deems that I
have violated the conventions of the practicums location (dress code, actions, language, etc.) or
population (residents, visitors, etc.) and have acted in a thoroughly unprofessional manner, he/she must
notify me immediately, informing me of what infraction has been committed, how it may be rectified, and
discuss whether dismissal or if reprimand should occur, and regardless of infraction degree or outcome,
notification with the course instructor (R. Andrew Brown) will occur.

As the undersigned, I agree to follow all policies and rules which apply to me at the site of my practicum
experience, bowing to my profile/guides judgement. Particularly, if a schedule has been set, I am
responsible for being present, on time, properly equipped and ready to begin observation, and if
applicable, participation. Should I miss scheduled practicum times, I am responsible for accepting
responsibility for my actions, including any sanctions deemed necessary by the practicum guide.
Absence should be cleared with the experience guide prior to occurring, if possible, as expected of
anyone functioning in a professional setting.
This confidentiality and policy statement is required for initiating the practicum; therefore, this
form must be signed by all those indicated below and returned for safekeeping in the course
records. A copy must be made available and provided for each party upon request. The practicum
cannot officially begin until this requirement has been met.

I, as student, agree to what is stated above and willingly sign this contract.
Printed Name:
I, as Profile Subject (individual or site manager), agree to what is stated above and willing sign this
contract as monitor.
Printed Name:
I, as course instructor, agree to what is stated above and willingly sign this contract as broker.
Printed Name: