Appendix 1
Consent Form for Audio or Visual Recording of a Service User
There are many reasons why filming, photographing or tape recording a particular condition, consultation or procedure is beneficial:
•To have a record of how a condition changes
•To assist in treatment
•To help train staff
•To help supervise the staff who are treating you
•To inform people about treatments available and what they involve
We must, however, ensure the interests and well-being of our service users are paramount and we have a duty to keep information about service users confidential.
Before any recording or photography takes place someone will explain to you the purpose of why this is being done and what the recording or photography will be used for. You will then be asked to sign overleaf to confirm your agreement.
After signing the consent you will have the right to:
•Have any recording stopped if you request it or if it is having an adverse effect on the consultation.
•See the video recording in the form in which it is intended to be shown.
•Vary or withdraw consent at that stage – if you withdraw consent the film, audio recording or photographic image will be destroyed as soon as possible.
•Agree to any proposed changes in the use of the recorded material.
If you withhold or withdraw your consent this will not in any way affect your treatment or the relationship of the clinicians treating you.
All recordings will be stored securely in the same manner as a medical record.
Northumberland, Tyne and Wear NHS Foundation Trust
Appendix 1 – Consent Form for Audio or Visual Recording of a Service User – Issue 2 – Oct 17
NTW(O)45 - Visual Imaging and Audio Policy – V06 .2
CONSENT FORM FOR AUDIO OR VISUAL RECORDING OF A SERVICE USER
Type of recording: (please tick)
□ Photograph – still image □ Audio □ Video□ Other (specify)………………………………………………………….
Date(s) of recording…………………………………………………
Purpose of the recording: (please tick as many as apply)
□ Record of treatment/assessment □ Staff training
□ Staff assessment/supervision □ Clinical audit
□ Research □ Other (specify)……………………………………………………………………………………………
To whom will the recording be shown:
(Anyone who receives information from us is also under a legal duty to keep it confidential).
□ Staff treating the patient
□ Staff in the department treating the patient for training purposes
□ Other staff for training purposes
□ Other (please detail organisation and title of person)……………………………………………………………………………………………………………………..
The information will be retained for (please specify) ……………………(years)
Location of recording whilst stored...... ……………………………
Encryption will/will not be used when transporting between sites
Recording undertaken by:
NAME: ………………………………… SIGNED:………………………………..
DATE: ……………. DEPARTMENT: …………………………......
I have read this form and consent to being recorded for the purpose(s) stated above.
NAME:……………………………….. SIGNED ……………………………. DATE…………….
(Service User)
I confirm that to the best of my knowledge and belief, that the service user understands the above, is able to consent and gives that consent willingly and on an informed basis.
NAME:……………………………SIGNED…….……………..……DATE…………….
(Clinician)
For patients or children unable to give consent:
Consent discussed with parent/person with parental responsibility or nearest relative.
NAME:……………………………SIGNED.. …..……………………………..DATE ……………………
Relationship to service user ………………………………………….…………………………………
• Original consent form to be filed in Section 8 of the Integrated Health and Social Care Record.
• Copy to be given to the service user/parent for information? Y/N
This page to be printed on the reverse of the consent form.
Use this form to note details of any access to the recording of the service user.
Date / Name of person accessing recording / Job Title / Reasons for access / SignatureNorthumberland, Tyne and Wear NHS Foundation Trust
Appendix 1 – Consent Form for Audio or Visual Recording of a Service User – Issue 2 – Oct 17
NTW(O)45 - Visual Imaging and Audio Policy – V06 .2