Consent Form

Informed Consent and Permission Form

for use of Patient’s Personal and Medical Information and Images

including Photographs, Case Studies, Video or Film

Background and rationale

Patients for Patient Safety US facilitates the sharing of patient experience and the engagement of patients or their advocates in patient safety improvement work.  We do so by sharing our stories with multiple audiences, including other patients and families, government policymakers, educators, healthcare providers and others. The goal of sharing is advocacy and education aimed at promoting patient engagement and patient safety culture. A person wishing to have his/her/their story shared is invited to give PFPS permission to use personal or medical information as well as images, such as photographs, films or video footage. This material can be provided by patients themselves or their parents, guardians or advocates. Presentations, articles or case studies also are welcome and useful.

PFPS use of the material provided may include, but is not limited to, editing, duplication, licensing, distribution and incorporation in other works. It may be used in both electronic or hard copy formats such as posters, presentations, publications, web sites, films or videos, among others.

Giving PFPS US permission to use my material is a license, not a transfer of ownership. Nothing in this Informed Consent and Permission Form shall transfer ownership or prohibit the provider of information or images to use it in his/her/their other advocacy work or with other advocacy organizations.

Procedure

PFPS US uses this Informed Consent and Permission Form to document your permission to share experience with others. Sharing or allowing your information to be used for PFPS US advocacy work is completely voluntary. You may choose to share all or part of your information. You may also choose to be identified by name or to share your experience or images without identification by name. This is entirely up to you.

For sharing the experience or images of minors, that is those who are younger than 18 years, or persons with a guardian, we would ask parents or guardians to complete this Informed Consent and Permission Form. When the person who is a minor turns 18 years, we invite you to sign your Informed Consent and Permission Form again.

For patient advocates who share the experiences or images of family members, including family members who are deceased, we ask you to certify that you either have permission of the people mentioned or whose image is shared or do not need permission to share because the person is deceased.

By signing this Informed Consent and Permission Form the person signing gives PFPS US a license to use the material, without payment or any obligation on the part of PFPS US to seek further authorization for each use.  Your sharing of information and images is voluntary at all times. You can withdraw your permission to use at any time by you informing PFPS US in writing.

For further information or clarification

If you have any questions or would like to discuss, you may contact: info@pfps.us

Consent to Use Personal or Medical Information, Images or Case Studies

I confirm that I have read (or have heard read to me) the Background Rationale and Procedure for PFPS US use of personal or medical information, images (including photographs, video or film) or case studies relating to myself, a minor for whom I am parent, a person for whom I am guardian or a deceased person. I am an adult (aged 18 years or older) and have the full right to make this declaration of consent and give PFPS US permission to use this material. If I include the names or images of family members, I declare that I have either their permission to do so or the legal right to do so.

I am informed that allowing PFPS US to use my experience, including written material images, is voluntary and that I will not be entitled to receive any payment. I am informed that I can withdraw my consent and permission to use at any time by notifying PFPS US in writing.

I understand that PFPS US reserves the right to make editorial decisions to use or not to use any of the material I share. The use of the above may include, but is not limited to, editing, duplication, licensing, distribution, or incorporation in other works.  PFPS Us may be in hard copy or electronic formats, such as posters, presentations, publications, web sites, films or videos.   When permission is given by signing this form, PFPS US has no obligation to seek further authorization for each use.

I understand that nothing in this declaration shall transfer ownership or prohibit me from using information or images I provide in either my own advocacy work or with other advocacy organizations.