A. Consent Agreement
LEVEL OF CONFIDENTIALITY
Information Sheet
Purpose of this Form:
You are being asked to sign
this separate consent form if you wish to have your name used publicly in the
sharing of the results of this study.
Please review the information carefully and feel free to ask questions
of regional coordinator, the project coordinator or the principal investigator
before you sign this form.
Some participants will choose
to have steps taken to protect their confidentiality throughout the
project. Other participants may
wish to have their names affiliated with the final report in the acknowledgement
section or even with specific pieces of data such as a quotation. We recommend that you wait until you
have a chance to review the draft final reports before providing consent to
have your name used.
Levels of
Confidentiality:
Level 1: all steps are taken
to protect confidentiality (you do not have to submit this form).
Level 2: you wish to have
your name in the acknowledgement section of the report but not in association
with any specific piece of data.
Level 3: you wish to have
your name in the acknowledgement section of the report and in association with
any piece of information provided through the study such as a quotation.
Benefits
You will receive public
credit for your contribution through either level 2 or 3.
Risks
It is important that you have
a chance to review the draft versions of the reports before you choose to have
your name publicly associated with it.
There is a risk with confidentiality level 2 (name in acknowledgements)
that you will be more likely identified with specific information that you
provided than if your name was not be made public. People could also guess that you might have said something
that in fact another participant said.
If you wish a level 3 (name
used in acknowledgement and in association with information provided) you will
have no protection of anonymity or confidentiality. People may become upset about the information you
shared. It is hard to predict the
type of responses that others might have.
Some users of home support fear that if their identity does not remain
hidden, administrators may reduce their levels of home support. Please feel free to explore the
ramifications of this choice with the regional coordinator, the project
coordinator and/or the principal investigator. Request for level three will not be approved without a
direct conversation with the regional coordinator and the principal
investigator about the risks involved.
Terms of the Agreement:
The principal researcher or
the research team reserves the right to not use real names in association with
specific data if it appears to not be in the best interest of the project, CCD,
Ryerson, the individual or any other participant involved in the study.
If you have Questions,
Please Contact Us:
|
Project Coordinator/Health Committee |
Principal Investigator |
|
Maureen Colgan, Project Coordinator
or Mary Ennis, Health Reform
Committee Council of Canadians with
Disabilities 926-294 Portage Avenue Winnipeg, Manitoba R3C 0B9 Tel: 204 947-0303 or 1 866 947-0303 (toll
free) Fax 204 942-4625 |
Kari Krogh, Ph.D. School of Disability
Studies Ryerson University 350 Victoria Street Toronto, Ontario Canada M5B 2K3 416 979 5000 ext. 7909 |
________________________________________________
Informed Consent Form
My signature below indicates
that I have read the “Information Sheet” above in this agreement
and that I have had a chance to ask any questions I might have about the study.
I understand the benefits and risks to myself. I have been told that by signing this consent agreement I am
not giving up any of my legal rights and that I may withdraw from the study at
any time. I also understand that I will be given a copy of this signed
agreement to keep.
Level of Confidentiality
(2 or 3 above) Desired:
1. Participant Signature
Name of Participant (please print):
____________________________________________________
Signature of Participant:
____________________________________________________________
Date:
___________________________________________________________________________
Contact Information for Participant
Address:
_________________________________________________________________________
Phone:
___________________________________________________________________________
Email:
___________________________________________________________________________
2. Regional Coordinator (collecting this form)
Regional Coordinator (please print):
____________________________________________________
Signature of Regional Coordinator:
_____________________________________________________
Date:
_____________________________________________________________________________
3. Principal Investigator
Name of Principal Investigator (please
print): _____________________________________________
Signature of Principal Investigator:
_____________________________________________________
Date:
_____________________________________________________________________________