{# traffic_light_decision_form.html #} {% extends 'base_pdf.html' %} {% comment %} template parameters: patient_lookup: PatientLookup settings: Django settings object {% endcomment %} {% block content %} {% block logo %}
Cambridgeshire & Peterborough NHS Foundation Trust (CPFT) is involved in health research for the benefit of patients. We’d like to know your view on being contacted about research studies that may be relevant to you, and being invited to take part.
{% include "phrase_never_affect.html" %}Please read the accompanying leaflet, “Taking part in research”. We’ll never give researchers information that can identify you without your permission.
If our researchers wish to write to you about relevant research projects, which of these three options would you prefer? Please tick one.
( ) | RED. I am not interested in being contacted about research. Don’t pass my details on to any researchers outside my clinical team. | |
( ) |
YELLOW. I’m not sure yet. Please ask my CPFT
clinicians to consider any requests from research teams
and pass them on to me if appropriate.
I will choose each time whether researchers can have
access to my CPFT records and write to me.
If you do not express a preference, this is the option that we will assume. |
|
( ) | GREEN. I am happy to hear directly from approved CPFT researchers inside or outside my clinical team. Please allow these researchers access to my full CPFT records and allow them to write to me about projects that might be suited to me. I understand that there’s no commitment to take part in any particular project. |
If you’ve chosen Yellow or Green, we will normally contact you by letter. Would you prefer us to e-mail you instead? Tick below if you would.
[ ] | Please use e-mail where possible. | |
E-mail address: |
CPFT routinely anonymises information for use in improving health care and for research. You can opt out from the use of your information for research even after all details that could identify you have been removed. Tick below if you want to opt out entirely. This is completely separate from being contacted about research.
[ ] | Opt out: don’t use my information for medical research, even after all the information that could identify me has been removed. |
Please turn over.
Please sign and date below.
By signing you also agree that the CPFT Research Database Manager (who is independent of any research team) can see the information you provide on this form (but not your medical details), so that they can record your choice and send you a letter of confirmation.
You can tell us at any time if you want to change your preference.
{% include "signature_box_patient.html" with patient_lookup=patient_lookup %}If any of your details are incorrect, we apologize; please correct them above.
{% if patient_lookup.is_under_15 %}As you are under 16, please also fill in the box below.
{% elif patient_lookup.is_under_16 %} {# Might have been sent out with 16th birthday approaching, etc. #}If you are under 16, or another adult is making decisions on your behalf, please also fill in the relevant box below.
{% else %}If another adult is making decisions on your behalf, please also fill in the box below.
{% endif %}Please return this form to The CPFT Research Database Manager, FREEPOST CPFT RESEARCH DATABASE MANAGER. Postage is free, and an envelope is enclosed. You can also give this form to a member of staff at CPFT. If you would like more information from your health care professional before completing this form, please feel free to ask.
Thank you!
{% include "consent_table.html" with settings=settings patient_lookup=patient_lookup LEAFLET_URL_CPFTRD_CLINRES_SHORT=LEAFLET_URL_CPFTRD_CLINRES_SHORT with_page_break=False %} {% endblock content %}