WP E-Signature by Approve Me - Sign Documents Using WordPress -

Parenting Through Change Consent Form

Explanation/Consent of GenerationPMTO conducted by Implementation Sciences International, Inc. (ISII)
GenerationPMTO Parent Client of Oregon Community Programs and Parenting Through Change.

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 therapists
ISII 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 Group Leader, if you agree, clients (i.e., you and your child(ren)) will be in the video as well as the Group Leader to observe
your reactions to the sessions.

Monitoring fidelity
Group Leaders 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 that evaluates 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 Group Leaders’ work are stored on the “ISII Portal” while videos used for the FIMP Raters are stored on “FIMP Central.”

Procedures:
Your Group Leader previously agreed to be videotaped in therapy sessions for training purposes. Although the focus of the videotaping is the Group Leader, 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 Group Leader is not employed by ISII, it will be the decision of the Group Leader or the Group Leader's agency whether they keep a copy of the video in their files after uploading to the ISII Portal.

Group Leaders 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 Portal
Video recording of sessions is an essential part of GenerationPMTO and allows ISII Coaches to give specific feedback to Group Leaderd 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 Central
We 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 registrar@generationpmto.org.

Voluntary Participation & Right to Withdraw these assessments:
As outlined above, video recordings of group sessions are a necessary step in the process of lodging Parenting Through Change group therapy at our organization.

PTC group sessions will be securely shared and viewed by ISII consultants so they may provide feedback to Group Leaders who are working toward becoming certified in delivering the intervention. Feedback and coaching is required to ensure we are delivering the intervention to fidelity and providing you the very best service possible. Families who do not consent to video recording are eligible to participate in individual outpatient counseling. If you have questions or concerns, please contact OCP’s Outpatient Program Director, Evyan Stuart, at 541-743-4348.

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.

Yes

I have received written information about how to request that my video sessions be removed from the ISII Portal and/or FIMP Central.

Yes

I understand that this is not a time-limited consent and will contact ISII if I wish to withdraw my consent in the future.

By signing this consent, I am stating that I am legally authorized to consent for my child's participation.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

January 15, 2021 12:23 pm PDT

Parenting Through Change Consent Form Uploaded by OCP Documents - ocpdocs@oregoncp.org IP 10.0.10.40

January 15, 2021 12:58 pm PDT