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Western University Elborn College, Rm. 2597, London, ON, Canada N6G 1H1 t. 519.661.2111 ext. 82753 f. 519.850.2369 www.westernu.ca 1
CSD9649Evidence-BasedPracticePermissiontoUseDataforEducationalPurposes
Instructor:LisaArchibaldEmail:[email protected]
InformationabouttheCourseEvidence-basedpracticeinvolvestheuseofcurrentbestevidenceinmakingdecisionsaboutthecareofindividualclients.ThegoalofCSD9649istoprovidestudentswithpracticeincriticallyevaluatingtheevidencebaserelevanttoaclinicalquestion.ProjectInthiscourse,studentsapplytheprinciplesofevidence-basedpracticetoevaluateaclinicaltopicofinterest.Oneoptionalcomponentoftheprojectistoincluderelevantclinicaloutcomesfromoneormoreindividualswhoarereceiving(orhavereceived)servicesrelatedtotheclinicaltopicofinterest.TheprojectispresentedasaposterattheAnnualCommunicationSciencesandDisordersEvidenceBasedPracticePosterDay,andinawrittenpaperpostedonthecoursewebsite:http://www.uwo.ca/fhs/lwm/ebp/index.htmlPermissiontoUseDataforEducationalPurposesWeareaskingforpermissiontousetheinformationcollectedaspartofyourspeechandlanguageservicesbecausethatinformationisrelevanttoaprojectbeingcompletedaspartofthecourse.Participationisvoluntary.Youmayrefusethispermissionwithnoimpactonservicesyouarereceiving(orhavereceived).ConfidentialityAlloftheinformationusedintheprojectreportswillbede-identifiedandusedforeducationalpurposesonly.Yournameandotheridentifyinginformationwillnotbementionedinthecourseposterorpaper.TheposterandpapermaybeseenbycommunityvisitorstothePosterDayoranyonevisitingourwebsite.Yourdatawillnotbeusedforresearchpurposesorpublishedaspartofaresearchproject.ContactInformationIfyouhaveanyquestionsabouttheprojectorcourse,pleasecontact: LisaArchibald,Ph.D. UniversityofWesternOntario;SchoolofCommunicationSciences&Disorders Phone:(519)661-2111ext82753;Email:[email protected]___________________________________________ _________________________________________________StudentSLP(pleaseprint) SupervisingSLP&Affiliation(pleaseprint)
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CSD9649Evidence-BasedPractice
PermissiontoUseDataforEducationalPurposesInformedConsent
Ihavereadthepermissionform,havehadthenatureofthecourseandprojectexplainedtome,andIagreetoallowmyclinicaldatatobeused.Allquestionshavebeenansweredtomysatisfaction.___________________________________________________________________Name Signature Date___________________________________________________________________Name Signature Date(PERSONOBTAININGINFORMEDCONSENT)Onecopyofthisformwillberetainedbyyourspeechlanguagepathologist,andonecopywillbelockedinafilingcabinetinDr.Archibald’ssecureofficeatWesternUniversity.
