  {"id":3530,"date":"2023-01-10T14:37:43","date_gmt":"2023-01-10T20:37:43","guid":{"rendered":"https:\/\/uwm.edu\/bms-labs\/?page_id=3530"},"modified":"2024-07-19T10:04:59","modified_gmt":"2024-07-19T15:04:59","slug":"informed-consent-form","status":"publish","type":"page","link":"https:\/\/uwm.edu\/bms-labs\/laboratory-forms\/informed-consent-form\/","title":{"rendered":"Informed Consent Form"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-4117 size-full\" src=\"https:\/\/uwm.edu\/bms-labs\/wp-content\/uploads\/sites\/361\/2024\/06\/BMS-Program.jpg\" alt=\"\" width=\"334\" height=\"168\" srcset=\"https:\/\/uwm.edu\/bms-labs\/wp-content\/uploads\/sites\/361\/2024\/06\/BMS-Program.jpg 334w, https:\/\/uwm.edu\/bms-labs\/wp-content\/uploads\/sites\/361\/2024\/06\/BMS-Program-300x151.jpg 300w\" sizes=\"auto, (max-width: 334px) 100vw, 334px\" \/><\/p>\n<p><span style=\"color: #ffffff\"><strong>.<\/strong><\/span><\/p>\n<p><span style=\"color: #ffffff\"><strong>.<\/strong><\/span><\/p>\n<h1 style=\"text-align: center\"><strong>\u00a0<\/strong><a name=\"_Toc207383886\"><\/a><a name=\"_Toc111958559\"><\/a>INFORMED CONSENT FORM<\/h1>\n<h3>General Information:<\/h3>\n<p>You will be participating in classroom, laboratory, or clinical activities in which learning may utilize student subjects as part of the training procedures, demonstrations\/and or experiments.\u00a0 As part of your learning activities, you may be asked to perform specific skills or be asked to be the subject of specific skills practiced by other students.<\/p>\n<p>All learning activities that use student subjects will be conducted under the supervision of the instructor who has been assigned to teach the course.<\/p>\n<h3>Benefits:<\/h3>\n<p>The experiences listed below have been selected because they are skills essential to the learning process and the faculty believe that realistic practice is essential for optimum learning.\u00a0 Participation will enhance the learning process and the acquisition of technical skills.\u00a0 An alternative experience may not provide as realistic an opportunity to practice and, therefore, may result in less effective learning.\u00a0 Specific benefits are listed below.<\/p>\n<h3>Risks\/Discomforts:<\/h3>\n<p>Participation may create some anxiety for you.\u00a0 Some of the procedures may create minor physical discomfort.\u00a0 Specific risks\/discomforts are listed below.<\/p>\n<h3>Your Rights:<\/h3>\n<p>You have the right to withdraw consent for participation and to withdraw consent after it has been given.\u00a0 If you withhold consent, you may be required to participate in an alternative learning experience.\u00a0 If you do not participate in either the planned or the alternative activity, you may not be able to successfully complete the course.\u00a0 You may ask questions at any point if something is unclear to you.<\/p>\n<h3>Implied Consent:<\/h3>\n<p>If a student withholds consent for one of the activities listed below, but later chooses to participate, they must submit a new Informed Consent Form indicating consent.\u00a0 It is the students responsibility to update this form.\u00a0 Students that submit an Informed Consent Form agree that they have read and understand the risks\/discomforts and benefits described for each activity.\u00a0 Consent will be implied if a student chooses to participate in one of the activities listed below after previously withholding consent.<\/p>\n\n<table id=\"tablepress-68\" class=\"tablepress tablepress-id-68\">\n<thead>\n<tr class=\"row-1\">\n\t<th class=\"column-1\">Learning Activity<\/th><th class=\"column-2\">Specific Benefits<\/th><th class=\"column-3\">Specific Risks\/Discomforts<\/th>\n<\/tr>\n<\/thead>\n<tbody class=\"row-striping row-hover\">\n<tr class=\"row-2\">\n\t<td class=\"column-1\">Venipuncture using syringe, vacutainer, &amp;\/or butterfly needle<\/td><td class=\"column-2\">Student gains experience needed prior to performing actual procedure on patients in clinical setting.<\/td><td class=\"column-3\">-Possibility of hematoma with venipuncture<br \/>\n-Slight temporary pain with puncture<\/td>\n<\/tr>\n<tr class=\"row-3\">\n\t<td class=\"column-1\">Capillary puncture using finger<\/td><td class=\"column-2\">Student gains experience needed prior to performing actual procedure on patients in clinical setting.<\/td><td class=\"column-3\">-Minimal possibility of infection when area is kept clean<br \/>\n-Slight temporary pain with puncture<\/td>\n<\/tr>\n<tr class=\"row-4\">\n\t<td class=\"column-1\">Urine collection (random, timed, or clean catch\/midstream)<\/td><td class=\"column-2\">Student gains experience needed prior to performing actual procedure on patients in clinical setting.<\/td><td class=\"column-3\">There are no risks or complications associated with a random, timed, or clean catch\/midstream urine collection.<\/td>\n<\/tr>\n<tr class=\"row-5\">\n\t<td class=\"column-1\">Throat swab collection<\/td><td class=\"column-2\">Student gains experience needed prior to performing actual procedure on patients in clinical setting.<\/td><td class=\"column-3\">There are no risks or complications associated with a throat swab collection.  The test may cause momentary gagging because the back of the throat is a sensitive area, but it should not be painful.<\/td>\n<\/tr>\n<tr class=\"row-6\">\n\t<td class=\"column-1\">Skin swab collection<\/td><td class=\"column-2\">Student gains experience needed prior to performing actual procedure on patients in clinical setting.<\/td><td class=\"column-3\">There are no risks or complications associated with a skin swab collection.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<!-- #tablepress-68 from cache -->\n<p>&nbsp;<\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_90' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Informed Consent Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_90'  action='\/bms-labs\/wp-json\/wp\/v2\/pages\/3530' data-formid='90' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Let4LkmAAAAAMDytJZITec55NB97k2BiShMXqPE' data-tabindex='0'><input id=\"input_b812b0031e54a835ecf4a0a94315c63f\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_b812b0031e54a835ecf4a0a94315c63f\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><ul id='gform_fields_90' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_90_1\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_1'>I have read the Informed Consent Form and understand the risks\/discomforts and benefits described.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_90_1' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_90_2\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_2'>I understand that I can ask my instructor or TA if I have any questions relating to this form or the activities described in the Informed Consent Form.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_2' id='input_90_2' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_90_11\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_11'>Choose One<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_90_11' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='I agree to participate in any of the learning experiences listed in the Informed Consent Form if required\/requested for a course' >I agree to participate in any of the learning experiences listed in the Informed Consent Form if required\/requested for a course<\/option><option value='I do NOT agree to participate in any of the learning experiences listed in the Informed Consent Form' >I do NOT agree to participate in any of the learning experiences listed in the Informed Consent Form<\/option><option value='I agree to participate in SOME of the learning experiences listed in the Informed Consent Form' >I agree to participate in SOME of the learning experiences listed in the Informed Consent Form<\/option><\/select><\/div><\/li><li id=\"field_90_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >I agree to participate in any of the listed learning activities EXCEPT: (Please check all learning activities that you DO NOT agree to participate in)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_90_12'><li class='gchoice gchoice_90_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Venipuncture'  id='choice_90_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_12_1' id='label_90_12_1' class='gform-field-label gform-field-label--type-inline'>Venipuncture<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_90_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Capillary puncture'  id='choice_90_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_12_2' id='label_90_12_2' class='gform-field-label gform-field-label--type-inline'>Capillary puncture<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_90_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Urine collection'  id='choice_90_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_12_3' id='label_90_12_3' class='gform-field-label gform-field-label--type-inline'>Urine collection<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_90_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Throat swab'  id='choice_90_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_12_4' id='label_90_12_4' class='gform-field-label gform-field-label--type-inline'>Throat swab<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_90_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='Skin swab'  id='choice_90_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_90_12_5' id='label_90_12_5' class='gform-field-label gform-field-label--type-inline'>Skin swab<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_90_14\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_14'>I understand that it is my responsibility to notify the instructor if I am asked to perform an activity that I do not wish to participate in.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_90_14' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_90_6\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_90_6'>\n                            \n                            <span id='input_90_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.3' id='input_90_6_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_90_6_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_90_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.6' id='input_90_6_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_90_6_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_90_7\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_7'>51ÁÔÆæ Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_90_7' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_90_9\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_9'>Instructor of course<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_90_9' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Shahla Anders' >Shahla Anders<\/option><option value='Brad De Pons' >Brad De Pons<\/option><option value='Dr. Jennifer Doll' >Dr. Jennifer Doll<\/option><option value='Dr. Stephen Hou' >Dr. Stephen Hou<\/option><option value='Dr. Elizabeth Liedhegner' >Dr. Elizabeth Liedhegner<\/option><option value='Dr. Zac Lunak' >Dr. Zac Lunak<\/option><option value='Dr. Dean Nardelli' >Dr. Dean Nardelli<\/option><option value='Dr. Troy Skwor' >Dr. Troy Skwor<\/option><option value='Other (please specify below)' >Other (please specify below)<\/option><\/select><\/div><\/li><li id=\"field_90_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_10'>Please type the name of instructor if OTHER is selected<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_90_10' type='text' value='' class='medium'    placeholder='Other' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_90_13\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_13'>Please type the email address of instructor if OTHER is selected<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_90_13' type='text' value='' class='medium'    placeholder='Other' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_90_8\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_90_8'>Please type your name in the box below.  Your typed name indicates agreement with the above statements.  Agreement is valid for 1 year following date of submission.  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