RESEARCH PARTICIPANT INFORMATION AND CONSENT FORM
Title of Study: “Interprofessional Education for Collaborative Patient-Centred
Practice: The Manitoba Initiative”
Principal Investigator:
Dr. Judy Anderson, Faculty of Medicine
Address: 101 Basic Medical Sciences Building, 727 McDermot Avenue,
Winnipeg, MB R3E 3P5
Telephone: (204) 789-3716
Facsimile: (204) 789-3920
E-mail: janders@ms.umanitoba.ca
Co-Investigator:
Dr. Christine Ateah, Faculty of Nursing
Address: Helen Glass Centre, University of Manitoba, Winnipeg, MB R3T 2N2
Canada
Tel 474-6220
Fax 474-7682
Email: Christine_Ateah@umanitoba.ca
Sponsor:
Health Canada, Health Human Resource Strategies Division
You are being asked to participate in a research study. Please take your time to review
this consent form and discuss any questions you may have with the study staff. You
may take your time to make your decision about participating in this study. This consent
form may contain words that you do not understand. Please ask the study staff to
explain any words or information that you do not clearly understand.
Purpose of Study
Interprofessional education, collaboration and patient-centred practice are essential for
improving the quality of patient care and patient safety, but are not standards in current
education programs. This Manitoba initiative (abbreviated IECPCP) involves 3
platforms, education, practice and research, to develop and sustain IECPCP.
One phase of the study is to demonstrate the effectiveness of collaborative, patientcentred practice by immersing small interprofessional groups of undergraduate health
professional students in one of four collaborative practice settings.
Study procedures
If you take part in this study, you will have an opportunity to participate in
questionnaires, focus group discussions and/or in-depth personal interviews.
The intent of your participation in the study is to understand your experiences with
students who were providing care as members of a health professional team.
Your personal time commitment would be determined by your level of participation. If
you are completing a surveyor questionnaire the time commitment would be less than
half an hour. If you participate in group discussions or personal interviews, your
commitment would not exceed two hours.
Risks and Discomforts
There are no identifiable or anticipated risks or discomforts associated with participation
in this study.
Benefits
There may or may not be direct benefit to you from participating in this study. Our goal
is to improve the quality of patient care by changing the way that health professional
students are educated so that they can be better prepared to work effectively in teams.
Costs
There will be no cost to you for participating in this study. You will not receive payment
for participation.
Confidentiality
Information gathered in this research study may be published or presented in public
forums; however your name and other identifying information will not be used or
revealed.
The University of Manitoba Health Research Ethics Board may review records related
to the study for quality assurance purposes.
All records will be kept in a locked secure area and only those persons identified will
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have access to these records.
Voluntary Participation/Withdrawal from the Study
Your decision to take part in this study is voluntary. You may refuse to participate or
you may withdraw from the study at any time.
If you are a patient, access to health care.
If you are a community-based preceptor, your decision not to participate or to withdraw
from the study will not affect your ability to participate in other aspects of this curriculum
development project.
Data Storage and Retrieval
All data will be kept at the University of Manitoba under the direction of the principal
investigator in a locked file cabinet or password-protected electronic form of storage.
Only the investigating team will have access to the data. All electronic, video, or printbased documents will be destroyed after analysis or upon completion of the study.
Medical Care for Injury Related to the Study
You are neither waiving any of your legal rights by signing this consent form nor
releasing the investigator(s) or the sponsor(s) from their legal and professional
responsibilities.
Questions
You are free to ask any questions that you may have about your participation in this
study and your rights as a research participant. If any questions come up during or
after the study or if you have a research-related injury, contact the study staff as
identified in this consent form.
For questions about your rights as a research participant, you may contact The
University of Manitoba, Bannatyne Campus Research Ethics Board Office at (204) 7893389
Do not sign this consent form unless you have had a chance to ask questions and have
received satisfactory answers to all of your questions.
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Statement of Consent
I have read this consent form. I have had the opportunity to discuss this research study
with Drs. Anderson and Ateah or their study staff. I have had my questions answered
by them in language I understand. The risks and benefits have been explained to me.
I believe that I have not been unduly influenced by any study team member to
participate in the research study by any statements or implied statements. Any
relationship I may have with the study team has not affected my decision to participate.
I understand that I will be given a copy of this consent form after signing it. I
understand that my participation in this study is voluntary and that I may choose to
withdraw at any time. I freely agree to participate in this research study.
I understand that information regarding my personal identity will be kept confidential,
but that confidentiality is not guaranteed. I authorize the inspection of any of my
records that relate to this study by The University of Manitoba Research Ethics Board,
for quality assurance purposes.
By signing this consent form, I have not waived any of the legal rights that I have as a
participant in a research study.
I agree to be contacted for future follow-up in relation to this study: Yes  No 
Participant signature: ____________________________ Date: _______________
Participant printed name: ____________________________
I, the undersigned, have fully explained the relevant details of this research study to the
participant named above and believe that the participant has understood and has
knowingly given their consent.
Printed Name: _________________________ Date: ___________________
Signature: ____________________________
Role in the study: ___________________________
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