HTF 402 National First Nations Telehealth Research Project
(46
K)
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.
THIS STUDY HAS BEEN EXPLAINED TO
ME.
I AGREE TO PARTICIPATE:
YES NO I agree to use/let my child use the telehealth
system.
YES NO I agree to have the forms filled out.
Signature: _______________________ Date: ____________
(Client/Parent/Legal
guardian)
Signature: _______________________ Date: ____________
(Health
staff member)
Name of translator: __________________________________
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:
THIS STUDY HAS BEEN EXPLAINED TO
ME.
I AGREE TO PARTICIPATE:
Signature: _______________________ Date: ____________
(Client/Parent/Legal
guardian)
Signature: _______________________ Date: ____________
(Telehealth/Telerehab
assistant)
Name of translator: __________________________________
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.
THIS STUDY HAS BEEN EXPLAINED TO
ME.
I AGREE TO PARTICIPATE:
YES NO I agree to use/let my child use the telehealth
system.
YES NO I agree to have the forms filled out.
Signature: _______________________ Date: ____________
(Client/Parent/Legal
guardian)
Signature: _______________________ Date: ____________
(Health
staff member)
Name of translator: __________________________________
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
THIS STUDY HAS BEEN EXPLAINED TO
ME.
I AGREE TO PARTICIPATE:
YES NO I agree to use/let my child use the telehealth
system.
YES NO I agree to have the forms filled out.
Signature: _______________________ Date: ____________
(Client/Parent/Legal
guardian)
Signature: _______________________ Date: ____________
(Health
staff member)
Name of translator: __________________________________
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.
THIS STUDY HAS BEEN EXPLAINED TO
ME.
I AGREE TO PARTICIPATE:
YES NO I agree to use/let my child use the telehealth
system.
YES NO I agree to have the forms filled out.
Signature: _______________________ Date: ____________
(Client/Parent/Legal
guardian)
Signature: _______________________ Date: ____________
(Health
staff member)
Name of translator: __________________________________
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