Virtual Group Informed Consent for Participation

Welcome to Red Deer Primary Care Network (RDPCN) group programs!
The RDPCN is excited to work and learn with you over the next few weeks, and want you to have a positive experience.
We ask you to review, and sign the following consent form.
At this time, and due to the COVID-19, we are offering our groups in a virtual (zoom) platform to provide easier access to workshops.
This will require the use of a device (laptop, desktop, tablet, or cell phone) that has access to both audio and camera and email for sending/receiving materials for the group (consent link, participant manual and evaluation link).

RDPCN Responsibility

  • Provides educational and skill based group programs to the public.
  • Provides trained health professionals to facilitate the groups.
  • Provides a safe environment for group programs.

Participant Responsibility

Attendance

  • To make every effort to attend on time,
  • If you miss a class;
    • We ask that you review the material for the missed week prior to the next class.
    • Advise the facilitator(s) or call the main office 403.314.3297 if you will be late or will miss a week.
  • If you miss more than 2 classes, we recommend that you consider register into the next group.
  • If you do not wish to remain in a group, and would like to withdraw, discuss the potential benefit of other resources with the facilitator(s) through the private chat option.

Participation

  • To get the most benefit and growth from our groups, we strongly recommend:
    • trying the activities,
    • participate in discussions,
    • Treat others in the group with the same courtesy that you would like to receive,
    • Encouragement and validation are appropriate,
    • Refrain from providing unsolicited advice
    • And importantly to complete the homework.
  • Virtual group participation and email technology does not have the same experience as in-person. However, the facilitators strive to ensure a positive group experience.
  • Some topics may be uncomfortable for you, and you have the option to decline to answer a question or take part in an activity. Feel free to discuss this with your facilitator(s) through the private chat option.
  • Safety is of utmost importance, therefore verbal harassment to others will not be tolerated.  Anyone who violates this rule will be removed from group and will be called by one of the facilitators to discuss expectations for returning.

Housekeeping

  • Mute your screen unless talking.
  • Ensure you have video/audio options on your device and connection to WiFi, to avoid any potential data overage fees.
    • It is recommended that you have a strong WIFI bandwidth, if your WiFi bandwidth is not strong we recommend to limit others on your network during class for the best experience.
  • If you need to leave the room before break, we ask that you give a group facilitator a thumbs up so they know that you are okay.  If you are gone for more than 5 minutes, one of the facilitators will call to check on you after class.
  • The RDPCN is not responsible for any data overage fees accrued during group. These fees are the client’s sole responsibility.

Evaluation

RDPCN conducts evaluation of all our programs, this helps the RDPCN ensure we offer high quality programs
Your involvement and feedback is valued and appreciated.
  • All evaluation is voluntary.
  • Any information you provide is kept confidential and, used only for the purposes of evaluating the program, your information will not be used in any way that can identify individual participants
  • In order to show progress and as part of the care provided by the RDPCN, it may be necessary to communicate aspects of the evaluation results with your doctor.

Confidentiality (Protections and Limitations)

  • All information shared by participants, will be kept confidential within the group.
  • RDPCN recommends to keep confidentiality within the group you are in a quiet and in a private location.  The use of headphones is also advised.
  • The participant note, will be sent to your doctor and kept on your medical record.
  • No information will be released to any other party except:
  • If there is a risk of harm to the participant or others,
  • If there is a risk of harm to a child or other vulnerable person,
  • If a lawyer subpoenas the records for a court case
I understand there are potential risks for virtual groups, including but not limited to:
  • interruptions,
  • risk of distractions,
  • unauthorized access,
  • potential of hackers,
  • time delays,
  • equipment failure, and
  • technical difficulties.

Today's Date

Fill in the personal information section then click on the "SUBMIT" button (located at the bottom of the page) to complete your registration.
Client / Guardian

First Name

Last Name

Client Alberta Health Care Number

Name of Family Doctor

Name of Clinic

Location of Clinic

Which group program are you participating in?

 Information on this form is collected under the authority of section 33(c) of FOIP and/or section 20(b) of HIA (pursuant to sections 27.1 and 27.2 of HIA) for the purposes of providing health services and carrying out planning and resource allocation, health system management, public health surveillance and health policy development. For more information about the collection of information on this form, please contact the Executive Director, Red Deer Primary Care Network at 403.343.9100.


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