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General Research Consent Form
Application Number:
Applicant Name:
Trust Use
Received:
Approved:
Signed:
Position:
Date:
Optometrist Name:
Optometrist Address:
Phone: Fax:
Email:
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General Research Consent Form Information
The Susan Larter Vision Trust will undertake research with Universities that teach optometry in Australia to improve the way Trust funds are spent and to improve outcomes for children receiving services under the program.
We would like your help with this and ask that you consider providing your consent for your child's information to be used for research purposes. If we would like your child to be part of a specific program we will be in touch and will advise you of this. You child's information will be treated as highly confidential and we will comply with the Privacy Act and University ethics requirements at all times
By agreeing to help us you will also be helping other children and assisting us to develop better optometry practice.
I have read and understood the information above and understand I may be contacted
about participation in specific research projects. The information has been fully explained
to me and I have been able to ask questions, all of which have been answered to my
satisfaction.
I understand that I don't have to take part in any particular study and that I can opt out at
any time. I understand that I don't have to give a reason for opting out and I understand
that opting out won't affect my future optometric care.
I understand that I will be made aware of any potential risks of any particular
research study.
Agreements
Yes
No
Yes
No
I give permission for researchers to look at my medical records to obtain preliminary
information. I have been assured that information about me will be kept private and
confidential.
Yes
No
Yes
No
Storage and future use of information:
I give my permission for information collected about me to be stored or electronically
processed for the purpose of scientific research and to be used in studies in the future
but only if the research is approved by a Research Ethics Committee, and I have been
contacted and given specific permission for each study.
Yes
No
Parent Name:
Parent Signature: Date:
Page 3 of 3To be completed by the treating optometrist or nominee.
I, the undersigned, have taken the time to fully explain to the above patient the nature and purpose of this consent in a way that they can understand. I have explained the risks involved as well as the possible benefits. I have invited them to ask questions on any aspect of the consent that concerned them.
· Signed consent to be submitted to the Susan Larter Vision Trust on application.
· Copy to be given to patient
· Optometrist to retain copy
Optometrist Name:
Optometrist Signature: Date:
Optometrist Qualifications
Practice Name:
Practice Address
