School of Health Professions Consent & Waiver for Participation as Sonography Volunteer

Transcription

1 School of Health Professions Consent & Waiver for Participation as Sonography Volunteer Participant s Name: : Gender: M or F DOB: I,, understand that I am participating as a volunteer for the Diagnostic Medical Sonography Lab at The University of Texas MD Anderson Cancer Center School of Health Professions (SHP) to receive an ultrasound procedure performed by a student of the SHP. Accordingly, I hereby fully agree to the following: 1. I voluntarily agree to participate as a sonographic subject and receive an ultrasound procedure performed by a sonography student at the SHP. I understand that this procedure is conducted in a teaching setting and as a teaching tool, and in no way constitutes a diagnostic examination. Neither the student nor the professor will interpret any of the images that are obtained. 2. I recognize that the ultrasound procedure that I will receive as part of my participation may involve potential risks and hazards, including but are not limited to feelings of discomfort due to having a full bladder, lightheadedness, fainting, slight pressure/pain, nausea, flushness, and incorrect gender identification. 3. If I feel nauseated, flush, or light headed, I understand this response is normal and that I will be asked to lay on my side until the feeling and/or sensation passes. 4. I understand that it is my responsibility to consult with my physician prior to my participation as a volunteer, and I agree that I will not participate if my physician, or other healthcare provider, indicates that such participation is unsafe to me or my fetus. 5. I agree to assume full responsibility for any risks, injuries, or damages, of any kind, which may occur as a result of receiving the sonographic procedure. 6. Waiver and Release of Liability: I knowingly and voluntarily waive any and all negligence and/or strict liability claims arising from or relating to my participation as a sonographic volunteer, and I agree to release from liability and hold harmless UT MD Anderson (and the School of Health Professions and its Diagnostic Medical Sonography Lab), its Agencies, Officers, and Employees for any accident, injury, illness, death, loss or damage to my person or property, arising from or relating to, directly or indirectly, my participation, or relating to information, gained or missed, as a result of this procedure, whether or not that information is accurate or inaccurate. Page 1 of 2 Consent & Waiver for Participation as Sonography Volunteer at School of Health Professions

2 I verify that l have read and understood this form, or have had this form read to me, and that any questions or concerns l may have had regarding this form have been fully resolved. I certify by signing below that l understand and agree with the contents of this consent and waiver form. Volunteer (or Legal Kin) Signature Printed Name of Volunteer (or Legal Kin) Relationship of Legal Kin to Volunteer, if applicable Witness Signature Faculty Signature _ Name of Translator (ID number), if applicable Signature of Translator, if applicable Page 2 of 2 Consent & Waiver for Participation as Sonography Volunteer at School of Health Professions

3 Primary Physician s Authorization for Volunteer Participant to Receive Sonographic Procedure at School of Health Professions Participant s Name: : Gender: M or F DOB: I, Dr., hereby give The University of Texas MD Anderson Cancer Center School of Health Professions (SHP) and its Diagnostic Medical Sonography Program (DMS) my authorization and permission to perform non-diagnostic obstetrical sonogram(s) on my current patient, whose name is:. As part of this authorization, I understand the following: This sonogram will be performed for teaching purposes only. The procedure will not constitute a complete medical exam, is not intended to be a diagnostic exam in anyway, and a report will not be generated with this sonogram procedure. No MD Anderson Physician will be involved in this procedure. The DMS faculty, who will be conducting this educational experience with the SHP student, are not physicians and they will not make any diagnoses. Someone from the DMS faculty may contact my office, at the number or address provided below, if they identify something in an image that they believe may warrant a diagnostic sonogram to be performed by my office. Due to the non-physician status of the DMS faculty, the DMS faculty may choose to err on the side of caution when developing their impression(s) and/or opinions(s) of the images, which form the basis for determining whether there exists a need to contact my office. If my office is contacted, the DMS faculty will not discuss their impression(s) or opinion(s) of the image(s) with me or anyone in my office. This patient had a normal sonogram on. In my medical judgment and opinion, there is no reason to prohibit this patient from participating as a volunteer to receive the sonographic procedure. Physician Signature Physician Printed Name Office Phone Number Physician Office Address Page 1 of 1 Primary Physician Authorization for Sonography Volunteer at School of Health Professions

4 School of Health Professions Sonography Volunteer Educational Information (Volunteers: please keep page 1, and sign and return page 2) This educational sheet is to inform all volunteers of important information related to their participation in the sonography program at the School of Health Professions, and to provide all volunteers with relevant rules, requirements, and expectations related to their participation. Please read the below information and keep for your reference (page 1). Please sign and return the attached Confirmation of Receipt form (page 2), which indicates that you have read and understand the below information. 1. There is no charge for this sonogram. 2. You may invite up to 3 guests to watch your sonogram with you. 3. You may NOT bring children under the age of 16 into the lab. 4. You must arrive to your appointment location no less than 20 minutes prior to your scheduled exam time. 5. Your scan will take approximately one hour. a. A student will spend approximately 45 minutes scanning you; b. The instructor may spend an additional 15 minutes scanning you. 6. Food or drinks are not allowed in the sonography lab. 7. We will provide OB volunteers with some keepsake images but you must supply the USB thumb drive upon which the images will be loaded. 8. Neither the professor nor the student will interpret the images, and they will not be able to answer all the questions you might have about the sonogram due to the restrictions of the American Registry for Diagnostic Medical Sonography (the credentialing body). 9. You will hear conversations between the professor and the student related to you and your fetus. These conversations will be educational in nature only and are part of the student s learning process. 10. The gender of your fetus will not be revealed to you unless specifically requested; gender identification is never 100% accurate. 11. To be eligible for this sonogram, you must meet the following requirements: a. You must be at least 18yrs old. b. You must have had a normal ultrasound for your current pregnancy prior to scheduling a sonogram with our lab. c. Your physician, or their designee, must provide you with the completed Primary Physician s Authorization form giving us permission to do this procedure. You should bring this signed form with you to the ultrasound lab. We will not do the sonogram without this signed form. It must be the original form; not a fax or photocopy. This procedure is performed by appointment only. Available days and times vary by semester. To schedule your sonogram, please send an with your name and phone number to: WTrawick@MDAnderson.org and put Volunteer in the subject line. Page 1 of 2 Educational Form for Sonography Volunteer at School of Health Professions

5 CONFIRMATION OF RECEIPT I verify that l have read and understand the information in the Sonography Volunteer Educational Information form, or have had the form read to me, and that any questions or concerns l may have had regarding the information in the form have been fully resolved. Volunteer (or Legal Kin) Signature Printed Name of Volunteer (or Legal Kin) Relationship of Legal Kin to Volunteer, if applicable _ Name of Translator (ID number), if applicable Signature of Translator, if applicable Page 2 of 2 Educational Form for Sonography Volunteer at School of Health Professions