VOLUNTARY CONSENT FORM
Purpose
The purpose of the tool, the Well Visit Planner (WVP), is to enable parents to optimize visit time by focusing on priorities, concerns, and other issues specific to the child and family. The WVP asks parents about their child and family and the kind of topics they want to discuss at their child’s well-child visit. The health care provider can use this information to customize the visit to the needs of the parent and child. Additionally, the tool provides educational information about potential discussion topics based on national recommendations for health care providers.
Procedures
To use this tool, complete the online Well Visit Planner which should take you about 10 minutes. You will be asked to do the following:
- Agree to the WVP Terms and Conditions.
- 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 WVP 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 during 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 may use at your child's well-visit. This guide highlights the topics you may want to discuss and should be brought to the visit.
- You have the option of creating your own account on the WVP. You can use your account to plan future visits, complete unfinished WVP visits, add other eligible children, and review previous Visit Guides and educational information.
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 discomfort. You may choose not to answer some of the questions. The choice is up to you.
Benefits
You may or may not benefit from using the online Well Visit Planner. However, by completing the online tool, 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.
The WVP does not collect protected health information or information that can lead to the identification of you or your child. You are asked to provide only two pieces of personally identifiable information: child’s first name (optional) and date of birth. These are not stored in our database. The child’s first name is displayed on the Visit Guide. The date of birth is used to calculate the appropriate upcoming well-visit and present the age-specific questions. That visit (e.g. 4 month or 6 month) is stored in our database rather than the date of birth. If you choose to create an account on the WVP, you have the option to add your child’s first name or nickname to appear on the family dashboard and Visit Guide. This name will be saved on our secure servers.
The email address that you use for registering an account will not be shared with any third parties, nor will your email address be sold or used for purposes other than sharing educational resources or sending updates about the Well Visit Planner. You can unsubscribe if you wish to stop receiving emails from us by sending us an email on innovatehealthcb@gmail.com.
In addition, identifying information connected to your computer (IP address) will not be recorded by the CAHMI at any time. If you choose to download or print your Visit Guide, CAHMI will not be liable for any actions related to your choice to disseminate, distribute or copy the Visit Guide with the name(s) of your child(ren) or any other information contained in the guide.
The Well Visit Planner will store the de-identified information that you provide about your child's health, development, and home environment; along with the priorities you select on a secure server. It will not be possible to link this anonymous information to you or your child. We will use this anonymous information to understand parents' concerns and priorities for their well-child visits. This information may also be combined with other parents’ responses and shared with your child’s provider to help them learn more about families they provide care to and improve well-child care for children and their families.
Costs
Access and use the Well Visit Planner is free.
You do not have to use the Well Visit Planner. If you do elect to use the Well Visit Planner, and later change your mind, you may discontinue use at any time. If you do not complete the WVP, there will be no penalty or loss of any benefits to which you are otherwise entitled.
If you have any questions, you may contact us at info@cahmi.org