Patient Partnership Pre-Screening

Patient Partnership Program
Consent to Disclosure and Use Information

Mohawk College's Patient Partnership Program aims to build a community of patients and family caregivers with unique experience and knowledge (gained through living with a condition or illness, receiving treatment or supporting a loved one) interested in sharing their perspectives to improve the way we deliver healthcare education. This information is intended to be used for case studies in the classroom setting and may be shared internally with faculty, staff, students and other stakeholders to help better understand healthcare care from the patient or family member perspective.

By engaging in Mohawk College's Patient Partner Program, you hereby grant to Mohawk College, a royalty-free, non-exclusive license to use any photographs, videos, stories, interview, opinions (“Work”) for research, educational, promotional, marketing and administrative purposes throughout the world in all languages in perpetuity in any and all media and formats whether now known or hereafter known or developed, in accordance with the provisions of this consent.

By providing your consent, you agree to share your information with Mohawk College in the following ways:

-Participation in committees or working groups
-Involvement in focus groups
-Sharing your experiences through presentations or panels
-Co-developing educational materials
-Engaging in one-on-one interviews
-Participating in events

You also agree to be contacted by Mohawk College regarding opportunities for involvement.

This consent will remain valid indefinitely unless you choose to withdraw it. To withdraw your consent, please contact patientsaspartners [at] mohawkcollege.ca.

By signing below, you acknowledge and agree:

• To permit Mohawk College to use your information in the manner specified above
• That you have read and understand this consent and agree to its terms
• That you have had the opportunity to ask questions about the consent and that you understand that you are free to withdraw your consent at any time

I have read and agree to abide by Mohawk's code of conduct as outlined in the following policies

• Respectful Workplace (Anti-Harassment and Anti-Discrimination) Policy
• Violence Prevention and Protection Policy
• Sexual Assault and Sexualized Violence Policy
• Health and Safety Policy