HTF 402 National First Nations Telehealth Research Project

Attachment 1: Consent Forms

Berens River TELEHEALTH CONSENT FORM

1. Purpose and Description

The purpose of this project is to obtain information about the use of telehealth technology in supporting and enhancing the care that patients in Berens River receive and in increasing the health care choices available to them. The telehealth system uses the television to let you/your child talk to a specialist doctor or a health educator in Winnipeg on a television set.

If you agree the nursing station staff will fill out a form about you/your child's visits. You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project.

2. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

3. Benefits

You/your child may be able to see the doctor or health educator sooner.

You/your child's followup treatments could be done at the Nursing Station.

You/your child might not have to travel to Winnipeg for treatment as often.

If the telehealth equipment is useful, it will stay in your community at the end of the project.

4. Risks and Discomfort

The doctor or health educator might not be able to see or hear you/your child as well as usual. This might make him or her miss something about your/your child's health problem. It might make him want to do more tests.

It is possible that the tests or treatment that you/your child needs will require you to travel to Winnipeg anyway.

You may feel that it is not as private as seeing the doctor or health educator in person.

5. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment, and you/your child will be able to see the same specialists as usual.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

6. Contact Persons

Your telehealth contact person here in Berens River is Joephine Berens. . You can reach her at: 204-382-2366.

Fort Chipewyan TELEHEALTH CONSENT FORM

1. Purpose

The purpose of this project is to obtain information about the use of telehealth technology in improving communication and community access to TELE-REHABILITATION, TELE-VISITATION AND TELE-SPIRITUALITY in a timely and cost-effective manner.

2. Description

The telehealth system uses the television to let you/your child talk to the Service Provider, family member or friend in For McMurray on a television set. The session might be video-taped.

If you agree the nursing station staff will fill out a form about you/your child's visits. You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project. Your name/your child's name will not be put on any of the questionnaires.

3. Benefits and Risks

You/your child may be able to see the Service provider, family member or friend sooner.

You/your child's follow-up treatments could be done at the Nursing Station.

You/your child might not have to travel to Fort McMurray for treatment as often.

If the telehealth equipment is useful, it will stay in our community at the end of the project.

You may feel that it is not as private as seeing the Service provider, family member or friend in person.

4. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

5. Contact Persons

Your contact persons here in Fort Chipewyan can be reached at 697-3091.

COOKIE SIMPSON - Telehealth Coordinator/ TAMMY BUCHANAN - Rehabilitation Assistant:

La Romaine TELEHEALTH CONSENT FORM

1. Purpose and Description

The purpose of this project is to obtain information about the use of telehealth technology in improving communications and community access to specialized care in the fields of diabetes, cardiology and otorhinolaryngology in a timely and cost-effective manner.

The telehealth system uses computer and communications technology to transmit images to Sept-Îles or Quebec City, in order to obtain diagnoses.

If you agree, the nursing station staff will fill out a form about your/your child's visits. You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Montreal that will compile the questionnaires for this project.

2. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

3. Benefits

Use of this technology could make your medical record more complete.

Your/your child's follow-up treatments could be done at the nursing station.

You/your child might be able to avoid travelling to Sept-Îles or Quebec City for treatment.

If the telehealth equipment proves useful, the community will be able to keep it at the end of the project.

4. Risks

Transmission of information by the telehealth system might not be secure.

It is not very likely, but information could be lost or images could be damaged.

There might be unusual delays in receiving the diagnosis from a specialist.

You may feel that this approach is less private than seeing a specialist or other care provider in person.

5. Voluntariness

There is no obligation for you/your child to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child may stop participating at any time.

You/your child may use the telehealth system without the forms or questionnaires being filled out.

6. Contact Persons

You can reach Daniel Goudnault, Telehealth Co-ordinator, at (418) 229-2042.

Southend TELEHEALTH CONSENT FORM I

1. Purpose

The purpose of this project is to obtain information about the use of telehealth technology in improving communication and community access to specialist consultations and patient education in a timely and cost-effective manner.

2. Description

The telehealth system uses the television to let you/your child talk to the Service Provider, family member or friend in Prince Albert on a television set.

If you agree the nursing station staff will fill out a form about you/your child's visits.

You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project.

3. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

4. Benefits and Risks

You/your child may be able to see the Service provider, family member or friend sooner.

You/your child's follow-up treatments could be done at the Nursing Station.

You/your child might not have to travel to Prince Albert for treatment as often.

If the telehealth equipment is useful, it will stay in our community at the end of the project.

You may feel that it is not as private as seeing the Service provider, family member or friend in person.

5. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

6. Contact Persons

Your contact persons here in Southend can be reached at 306 758-2063. JEANNE CLARKE - Telehealth Coordinator

Southend TELEHEALTH CONSENT FORM II (video)

1. Purpose

The purpose of this project is to obtain information about the use of telehealth technology in improving communication and community access to specialist consultations and patient education in a timely and cost-effective manner.

2. Description

The telehealth system uses the television to let you/your child talk to the Service Provider, family member or friend in Prince Albert on a television set.

The session will be videotaped.

If you agree the nursing station staff will fill out a form about you/your child's visits.

You/your child might be asked to fill out a questionnaire to let us know how the telehealth session went.

All the information will be sent to a research team at McGill University in Québec who will compile the questionnaires for this project.

3. Confidentiality

Your name/your child's name will not be put on any of the questionnaires. No one will have access to any information about your health status or your use of the telehealth system.

The videotape of the session will be stored under lock and key and will be destroyed at the end of the research project (March 2001).

4. benefits and Risks

You/your child may be able to see the Service provider, family member or friend sooner.

You/your child's follow-up treatments could be done at the Nursing Station.

You/your child might not have to travel to Prince Albert for treatment as often.

If the telehealth equipment is useful, it will stay in our community at the end of the project.

You may feel that it is not as private as seeing the Service provider, family member or friend in person.

5. Voluntariness

You/your child do not have to participate in this study.

If you don't, you/your child will receive the same care that you/your child would have received if we did not have this equipment.

You/your child have the right to stop participating at any time.

You/your child can use the telehealth system without having the forms or questionnaires filled out.

6. Contact Persons

Jeanne Clarke is the telehealth coordinator for Southend and can be reached at 306 758-2063.