TRAINEE AGREEMENT AND CONSENT FORM
This is a consent to participate in reproductive health training available through your professional training program. In addition to training, we hope to evaluate and improve the reproductive health curriculum for all participants.
Every learner eligible to participate in reproductive health training will be asked to evaluate the program, regardless of the level at which they opt to participate. Questions will involve your evaluation of the training, the competence you have gained, and the influence of the training on your future practice plans.
Your participation in the evaluation is voluntary.
As a participant in the Training Program, you will be asked to review and comply with the medical standards and mandated reporting for the training site, maintain confidentiality, and follow the clinical protocols of the training site.
You will also be asked to keep a record of your procedural experience (including ultrasounds, counseling, aspiration procedures, medication abortions, and any complications) during the rotation and in the subsequent two years. Note: Keeping a log and follow-up information will help you monitor your own practice. Training staff may also use this information on an anonymous basis in evaluating the effectiveness of training.
We will ensure that personal information gathered for this evaluation study is kept private and confidential. If information from this study is published or presented at scientific meetings, no names or personal information will be used.
If you have any questions, you may ask your faculty.
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CONSENT: You may print a copy of this consent form if you choose.
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Signature Date
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Witness Date