C ONSENT AND CAPACITY BOARD COMMISSION DU CONSENTEMENT ET

AUTHORIZATION AND CONSENT FOR DISCLOSURE OF CRIMINAL
APPENDIX H SURROGATE CONSENT PROCESS ADDENDUM THE
BUILDING PLATFORM CHECKLIST (VERSION NOV2019) RESOURCE CONSENT NO

CONSENTIMIENTO INFORMADO PARA LA UTILIZACIÓN DE MUESTRAS BIOLÓGICAS
ELECTROCONVULSIVE THERAPY (ECT) YOUR RIGHTS ABOUT CONSENT
INFORMED CONSENT FORM AND HIPAA AUTHORIZATION STUDY

PUBLIC INFORMATION PROGRAM

C onsent and Capacity Board Commission du consentement et de la capacité

151 Bloor St. West, 10^th Flr. 151 rue Bloor Ouest, 10^e étage

Toronto ON M5S 2T5 Toronto (Ontario) M5S 2T5

Telephone: (416) 327-4142 Téléphone: (416) 327-4142

Facsimile: (416) 327-4207 Télécopieur:(416) 327-4207

PUBLIC INFORMATION PROGRAM REQUEST FORM

Please complete the following Request Form, providing as much detail, as possible:

Date/Time of Proposed Event

 

Location of Proposed Event

 

Expected Number of Attendees

 

Expected Audience (i.e. psychiatrists, nurses, social workers, admin staff, etc)

 

Requested Subject Matter/Topic

 

Anticipated Benefit for Participants

 

Other Information for the Presenter

 

Requesting Organization/Individual

 

Contact Person(s)

 

Telephone Number

 

Facsimile Number

 

E-mail Address

 

Availability of Television/DVD (Yes/No)

 

Availability of LCD Projector/Screen (Yes/No)

 

Availability of Laptop/Computer (Yes/No)

 

Once completed, please return this Request Form to:

Ms. Amrita Zaman

Consent and Capacity Board

151 Bloor St. W., 10^th floor

Toronto, ON M5S 2T5

Telephone: (416) 212-6827

Facsimile: (416) 327-4207

[email protected]

Updated September 14, 2015

PATIENT ID NUMBER PATIENT NAME INFORMED CONSENT
TERMO DE CONSENTIMENTO DE USO DE BANCO DE
(REV 10919) INFORMED CONSENT FORM (ICF) TEMPLATE INFORMED CONSENT

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