Certification Appendix P-4

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Disclosure Agreement for Information
From Student Records *

I understand that as a member of the ACPE. Certification process, I may have access to information from confidential student records. I will not retain copies of those records or information, nor will I disclose or use any information I might obtain from them in any process other than the one in which I am currently authorized to participate.

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Signature of ACPE member

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Date

• Form is to be signed by anyone viewing or using student records in the context of a Certification review if student records will be viewed.