Template Consent Form for Patient Participants for use in video-based studies of healthcare provider-user communication – to be adapted according to the specifics of the study
Template Informed Consent Form for Patient Participants
Name of Researcher:
Name of Participant:
1. / I confirm that I have read and understand the Information sheet Version number ___ dated ____ for the above study and have had the opportunity to ask questions.2. / I understand that my participation is voluntary and I am free to withdraw at any time, without giving reasons, without my care being affected.
3. / I understand that one occasion when I saw a doctor at [setting] [was/will be] recorded, that the recording may be seen and heard by members of the research team, and that anonymous direct quotes from it may be used in study reports.
4. / I understand I may withdraw any time, and that if I withdraw before research reports and teaching videos have been finalised my information and recording won’t be used. If I withdraw after finalisation of reports and videos, then the information collected so far cannot be erased and may still be used.
5. / I agree to take part in the study.
6. / I authorise the research team to inform my GP about my participation
How my recording can be used
We will only use the recording in the ways you consent to. When we use your recording, your voice and image won’t be altered except that we will blank out people and place names.
A. / Use of the audio-recording for research purposes
I agree to use of a sound recording of this consultation in the research. I.e. that the research team may analyse, listen to, make and read transcripts, and take notes about the recording.
B. / Use of the video-recording for research purposes
I agree to use of both sound and images, i.e. a video recording of this consultation in the research. I.e. that the research team may analyse, listen to, watch, make and read transcripts, and take notes about it.
C. / Use of the recording for future research on communication
I understand that the current project aims to better understand communication relating to decision making and empathy.
I agree to use of the recording for future research aiming to better understand other areas of communication needed for good care
D. / I understand that I may, by request, view or listen to this recording any time before the end of the study [date] but that I will not be given a copy to keep.
In addition, where initialled, I agree to the following use(s) of my recording - being aware that person and place names will be removed, but my voice and image will not be altered.
i. / Transcripts may be shown to other researchers
I agree that transcripts from this recording may be used in closed sessions with other communication researchers, to help strengthen the research results
ii. / Clips may be played to other researchers
I agree clips from this recording may be used in closed sessions with other researchers, to help strengthen the research results.
iii. / Transcripts may be used for presentations about the research
I agree transcripts from this recording may be used in talks about this research for professional audiences of researchers, health and social care staff and trainees.
iv. / Clips may be played at presentations about the research
I agree clips from this recording may be used in talks about this research for professional audiences of researchers, health and social care staff and trainees.
v. / Stills may be used in published reports about the research I agree stills from my video recording may be used in published reports after blurring my face if it is visible.
vi. / Use of transcripts in communication skills training
I agree that transcripts from my recording may be read and used in communication skills training. I understand that person and place names in these transcripts will be changed to help anonymity.
vii. / Password-protected communication skills training videos
I agree that clips from my recording may be used in communication skills training. I understand that these will only be shown to restricted audiences during face to face training by professionals who teach communication to health and social care staff and trainees.
Signature of participant
Name of participant Date
Signature of person taking consent
Name of person taking consent Date
3 copies: 1 for participant, 1 for the project files and 1 for the medical records
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Supplementary file to Parry R., Pino M., Faull C., and Feathers L. (2016). Acceptability and design of video-based research on healthcare communication: evidence and recommendations. Patient Education and Counselling.