Informed consent for use of patient’s personal and clinical information and images (including photographs, case studies and films)
Background and rationale
Several patient advocate organizations have become aligned with the Safety Across the Board Pledge of Partnership. We seek to convey in person, by voice, and in words, pictures, film and other audio and visual media the impact on patients and families made by preventable harm in health care. We also seek to draw attention to patient and family advocates who are making a difference. For these purposes we seekpermission to use your stories, presentations, any personal and clinical information you wish to share with us that is not confidential, as well as any images you provide, such as photographs, films, video footage. We seek this permission from patients or their parents or guardians who have the legal right to give permission.
Procedure
Sharing or allowing your information to be shared is a voluntary decision. You have the power to choose to share all or part of your information and/or images. You may choose to share your experience anonymously or to be identified by name. This is entirely up to you.
For patient advocates who are minors, that is those who are younger than 18 years, we would ask parents or guardians to complete the informed consent form. When you become18 years of age, we invite you to renew your permission by signingan informed consent form in your own name.
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 have permission to share such experiences or images.
Your contribution is completely voluntary. Should you change your mind later, you can withdraw your permission by informing us in writing.
For further information or clarification
If you have any questionsor would like to discuss any aspect of our use of your material, you may contact:
______
Declaration of consent: information, photographs, case studies and films
I confirm that I have read or have had read to me the Background and
Rationale and Procedure portions of this consent form. I am an adult (aged 18 years or older) andhave the full right to make this declaration of consent. 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 as their parent, guardian or survivor.
I understand that that permitting use of my experience in any form (information or images) is voluntary and that I will not be entitled to receive any payment for their use. I understand that I can withdraw my consent at any time by notifying ______in writing.
I give permission to ______to make editorial decisions to use or not to use any of the above. The use of the above may include, but is not limited to, editing, duplication, licensing, distribution and incorporation in other works, in whatever form (e.g. hard copy or electronic), such as posters, presentations, publications, web sites, films or videos, and their unrestricted use, without any obligation on the part of ______to seek further authorization for each use.
I acknowledge that an unrestricted right to use the aforesaid information, photographs, case studies or filmsislicensedto______, which shall have the sub-licensable and worldwide right to use the materials provided in any manner whatsoever. However, nothing in this declaration shall transfer ownership or prohibit me from using information or images I provide in my own life and work or with other organizations.
For the purpose of this consent form I am consenting for the use of information and/or images of: (Please tick the appropriate box)
myself a minor for who I am parent/guardian
family members described in written materials and/or pictured in images
I consent for ______to use the following:
(Please check all that apply)
My name (that is to be identified by name if it so required)
Personal/clinical information
Photographs
Video footage
I do not consent to ______using any of the above.
I, the undersigned, hereby consent to the use of my likeness, biography, pictures, presentations and other materials related to myself, a minor for whom I am responsible or other persons who might be deceased, for use in reports, presentations, publicationsphotographs, case studies and films made by or for ______.
Signature: ...... Date: ......
Name: ...... Place: ......
[You may type your name and then send by email. Please send it by yourself as your email will be considered a part of your signature.]