Page 58 - Experience Based Co-design - a toolkit for Australia
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 Consent for interview and Audio/Video Recording
This consent form tells that you understand and agree to
being interviewed and recorded. Please tick the following if appropriate:
I have read and understood the information sheet about this project and have had the opportunity to ask questions
I understand that my comments (or part of them) may be used in different formats such as video, paper and/or electronic to share with others for the benefits of designing services that are based on patient experience
I understand that my participation is voluntary and I am free to withdraw at any time
I know that I can ask for any comments I have made on tape, or in writing or on film to be removed
I understand that any of my comments used may be transcribed and will appear anonymously.
     I agree to take part in the above project.
Yes No
Signing below indicates you agree. Patient Name:
Signature: Date:
Interviewer Name:
Signature: Date:
  Adapted from the EBD approach, NHS Institute for Innovation and Improvement

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