Explanation/Consent of GenerationPMTO conducted by Implementation Sciences International, Inc. (ISII)
GenerationPMTO Parent Client
Client Name: Client Date of Birth:
Options Location:Options Counseling and Family Services Location: Beaverton - 8285 SW Nimbus Ave, Ste 148; Beaverton, OR 97008 Fax: (503)352-3262Clackamas - 12901 SE 97th Ave, Ste 340; Clackamas, OR 97015 Fax: (503)655-6806Eugene - 1255 Pearl St, Ste 102; Eugene, OR 97401 Fax: (541)687-2063Florence - 1445 8th St; Florence, OR 97439 Fax: (541)997-8606Multnomah - 11010 SE Division St, Ste 202; Portland, OR 97266 Fax: (503)335-5974Newport - 119 NE 4th St; Newport, OR 97365 Fax: (541)264-7515North Salem - 2645 Portland Road NE, Ste 120; Salem, OR 97301 Fax: (503)393-3135Roseburg - 283 SE Fowler St, Ste 2; Roseburg, OR 97470 Fax: (541)464-6457South Salem - 1515 Liberty St SE; Salem, OR 97302 Fax: (503)468-3130Springfield - 175 West B St, Bldg D; Springfield, OR 97477 Fax: (541)762-1974St. Helens - 445 Port Ave, Ste C; St. Helens, OR 97051 Fax: (503)335-5974Woodburn - 1320 Meridian Dr; Woodburn, OR 97071 Fax: (503)498-5810
Purpose of the Consent form:Implementation Sciences International, Inc. (ISII) is conducting an ongoing collection of data and we invite you to participate. There are two reasons we would like your permission for ISII to collect, store, and view video recordings of sessions in which you will be participating: coaching therapists and monitoring fidelity.
Coaching therapistsISII is providing training for therapists in GenerationPMTO. Videotaping individual sessions is an essential part of GenerationPMTO and allows ISII coaches to give specific feedback to therapists about their adherence to the core components of GenerationPMTO throughout the training process. Although the focus of the videotaping is the therapist, if you agree, clients (i.e., you and your child(ren)) will be in the video as well as the therapist to observe your reactions to the sessions.
Monitoring fidelityTherapists using the GenerationPMTO model are reviewed periodically to ensure they are doing the model correctly. This is done by using a rating system called Fidelity of Implementation (FIMP). FIMP Raters, who are also experienced GenerationPMTO therapists, view selected therapy sessions to certify that therapists are doing this model correctly. The FIMP Raters also need regular testing to make sure they are able to do their job accurately. FIMP Raters are tested annually by scoring short segments of real therapy sessions using a coding system thatevaluates the quality of the therapist’s GenerationPMTO work with families. We are asking for your consent to allow short segments of therapy sessions in which you participated to be used for this purpose.We use two separate databases for this work. Videos used for evaluating therapists’ work are stored on the “ISII Portal” while videos used for the FIMP Raters are stored on “FIMP Central.”
Procedures:Your therapist previously agreed to be videotaped in therapy sessions for training purposes. Although the focus of the videotaping is the therapist, clients (i.e., you and your child(ren)) would also be in the video to observe you and your family’s reactions to the therapy. We would like your permission for ISII to collect, store, and view video recordings of sessions in which you will be participating.
ISII will only use these video images for coaching, training, educational and research purposes. These video recordings will become the property of ISII. To ensure confidentiality, all information will be coded so that it cannot be associated with any individual’s name. If the therapist is not employed by ISII, it will be the decision of the therapist or the therapist’s agency whether they keep a copy of the video in their files after uploading to the ISII Portal.
Therapists will be asked to upload the video-recorded therapy sessions to the ISII Portal in order for ISII coaches to review their work as therapists. Then, short segments may be uploaded to the FIMP Central database for use by the FIMP Raters, to test their work as raters. More explanations for the two databases:
ISII PortalVideo recording of sessions is an essential part of GenerationPMTO and allows ISII Coaches to give specific feedback to therapists about their adherence to the core components of GenerationPMTO. The video recordings will be stored on a web-accessible, secure, password-protected server as well as on backup drives housed onsite. This password-protected online database, referred to as the “ISII Portal,” is the property of ISII and meets current HIPAA standards for security and confidentiality. It is only accessible to authorized ISII staff.
FIMP CentralWe are also requesting your permission to use short segments of some sessions for the purposes of ensuring the quality of GenerationPMTO treatment as evaluated by trained FIMP Raters.
The FIMP Raters will review selected 10-15 minute segments of the videotaped sessions to rate the sessions. Some sessions are selected to make sure the FIMP Raters are scoring the sessions accurately in terms of the model and their rating of therapists’ work.
The video segments will be stored and available for the FIMP Raters to view in an electronically secure online location called “FIMP Central.” This password-protected online database is the property of ISII and meets current HIPAA standards for security and confidentiality. It is only accessible to authorized FIMP Rater teams.
Potential risks, discomforts or inconvenience:Potential discomfort and risks involved in your participation in this collection include: possible violation of confidentiality and possible embarrassment in disclosing sensitive personal information. To protect you from the potential risks, we have taken a number of steps, identified below.
Confidentiality of records:To ensure confidentiality, all information will be coded so that it cannot be associated with any individual’s name. The ISII Portal and FIMP Central databases are only accessible to ISII staff and authorized GenerationPMTO FIMP Raters.
All videos will be used respectfully and confidentially for education, training, coaching, supervision, and research as outlined above.
The confidentiality of your records will be protected to the maximum extent permitted by law. As a participant in this model, you should be aware that there are exceptions to confidentiality. Exceptions include: if evidence of suspected abuse or threatened abuse is discovered, it must be reported to authorities.
Potential benefits:Potential indirect or future benefits that may result from your participation in this model include the following:
1. The information gathered will be used to support the correct implementation of GenerationPMTO model.2. It may improve the quality of services for other children and families wherever GenerationPMTO is practiced.
There may be no potential direct benefits to you or your child(ren) from your participation in this model.
Contact Information:During the course of your participation in GenerationPMTO, you may have questions about the data collection or the treatment procedures. Your therapist may be able to answer these questions, or you may speak with the ISII Administrator (541-485-2711) or firstname.lastname@example.org.
Voluntary Participation & Right to Withdraw these assessments: Your participation in this data collection is voluntary. Your refusal to participate in this collection will involve nopenalty or loss of benefits to which you are otherwise entitled. You have the right to withdraw from thiscollection at any time, and also can require that the video sessions that include you and your family be removedfrom the online database.
My signature below indicates my voluntary agreement to allow my video-recorded sessions to be uploaded to the ISII Portal and used as outlined above. YesNo My signature below indicates my voluntary agreement to allow selected segments of therapy sessions to be uploaded to FIMP Central and used as outlined above. YesNo I want to view the selected segments before submitting to FIMP Central YesNo I do not wish to view the selected segments before submitting to FIMP Central YesNo I have received written information about how to request that my video sessions be removed from the ISII Portal and/or FIMP Central. YesNo I understand that this is not a time-limited consent and will contact ISII if I wish to withdraw my consent in thefuture.
Request for GenerationPMTO therapy session segments (FIMP spots) to be withdrawn
At any time you have the right to withdraw and have your recordings deleted from the ISII Portal and/or FIMP Central online databases with no penalty or loss of benefits to which you are otherwise entitled to.Please follow the outlined steps:
1. Notify the ISII Administrator at 541-485-2711, email@example.com or where you received the services or training.2. Let them know that you signed a release for therapy session videos to be used on the ISII Portal and/or FIMP Central and wish to ave your videos withdrawn.3. They will notify IT Support and will have your videos removed.4. You will then receive notice from ISII Administrator that this action has happened.5. If you have not received notice, please contact the location where you received services.
By signing this consent, I am stating that I am legally authorized to consent for my child’s participation
Client Name : Therapist Name
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Document Name: Explanation/Consent of GenerationPMTO conducted by Implementation Sciences International, Inc. (ISII)
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