Consent

Well-Visit Planner Public Use Website (Approved by the Institutional Review Board at Oregon Health & Science University, Protocol #00009050 on 12/31/12)

VOLUNTARY CONSENT FORM

Purpose

This free online tool -- Well-Visit Planner (WVP) is intended to help you prepare for your child’s well child visit by asking you (parents) to voluntarily answer questions about your child and what kinds of topics you want to discuss at your child's well-child visit. This allows your health care provider to use this information to customize the visit to your needs. The online tool also provides educational information to you about topics that are recommended for discussion at each well-child visit. You and your child’s provider can voluntarily use the tool to improve your time together during each well-child visit from 4 months of age to 6 years of age.

Procedures

If you voluntarily choose to use this tool, it should take you between 10-15 minutes to complete the online Well-Visit Planner. You will be asked to do the following:

  • Voluntarily consent to participate in using the tool. You will be asked to voluntarily consent to allow the Child and Adolescent Health Measurement Initiative to mine the de-identified information that you provide in order to analyze and improve the tool.
  • Provide basic information about your child who has the upcoming well-child visit.
  • Answer a series of questions about your child and family that will help you and your child's health care provider know what they may need to focus on in the visit.
  • Pick the topics that you want your child's doctor to address and give you information about at the upcoming visit.
  • Receive a "Visit Guide" that you can voluntarily use at your child's well-visit. This guide highlights the topics you wanted to discuss and is intended to be brought to the visit.

If you have any questions regarding the Well-Visit Planner now or in the future, contact the Child and Adolescent Health Measurement Initiative at info@cahmi.org.

Risks

Although we have made every effort to protect your identity, there is a minimal risk of loss of confidentiality. Additionally, you may find that some questions or topics cause you emotional distress. You may choose not to answer any of the questions that you do not wish to answer.

Benefits

You may or may not benefit from using the online Well-Visit Planner. However, by completing the online survey, you may improve your child's well-visit and you may receive useful information in partnering with your child's health care provider. Additionally, the answers you provide may help your child's health care provider understand your child and family health so that they can better provide well-child care for you. Finally, your participation may help us learn how to benefit parents and children in the future by providing information to health care providers that will help them improve well-child visits.

Confidentiality

We implement a variety of security measures to maintain the safety of your personal information when you enter or submit answers. We offer the use of a secure server. All supplied sensitive information is housed in our database which is protected through a secure dedicated port which only allows data entry from the tool to our database. The database is protected by having a closed-off port for the SQL Server installation. Only authorized personnel with special access rights to our systems are given access to the data. We are required to keep the information confidential.

Personally identifiable information (your child's first name, your child's date of birth, and the date of your child's well-child visit) will NOT BE STORED on our server after you complete the Well-Visit Planner. In addition, identifying information connected to your computer (IP address) will not be recorded by the CAHMI at any time.

The Well-Visit Planner will store the de-identified information that you provide about your child's health, development, and home environment; and the priorities you select will be stored on a secure server. It will not be possible to link this anonymous information to you or your child.

Costs

It will not cost you anything to participate or use the Well-Visit Planner.

Participation

If you have any questions regarding your rights as a participant, you may contact the OHSU Research Integrity Office at (503) 494-7887.

You do not have to participate in or use the Well-Visit Planner. If you do participate, and later change your mind, you may quit at any time. If you refuse to join or withdraw early, there will be no penalty or loss of any benefits to which you are otherwise entitled.

Principal Investigator

Christina Bethell, PhD MPH MBA       (443) 287-5092