Lived Experience Involvement Consent Form & Access Checklist

By completing this form, you are acknowledging that you have read and understood the following:

I have read the Involvement Information Sheet and understand the purpose of my involvement at Queen Margaret University
I understand that my involvement at Queen Margaret University will normally be on voluntary/honorary basis and I will be reimbursed travel expenses during this involvement
I consent to my personal details being processed for the purposes as set out in the Involvement Information Sheet and stored securely on the electronic Involvement Network Database for as long as I am participating in activities at Queen Margaret University. I understand that Queen Margaret University will process my personal data in accordance with its Data Protection Policy which can viewed here: Queen Margaret University Data Protection Policy (qmu.ac.uk) and Lived Experience Involvement - Privacy Notice
Queen Margaret University will endeavour to keep your personal details up to date and accurate however I understand it is my responsibility to notify the University of any changes or updates to my information.
I understand that I can request the erasure of my personal details from the electronic Involvement Network Database at any point by emailing HSLivedExperience@qmu.ac.uk
I understand that I can withdraw my participation in involvement activities at Queen Margaret University at any point by emailing HSLivedExperience@qmu.ac.uk
I understand that the information I choose to disclose during involvement activities at Queen Margaret University, that may relate to my diagnosis, intervention, or any other personal circumstances, will be held in confidence by both Queen Margaret University staff and learners on a strict need to know basis, and that such information will not be divulged to any third parties, unless explicit consent has been given to do so.
I agree that information disclosed by staff and learners that may relate to their health status, personal circumstances and the learning materials used at Queen Margaret University, will be held in confidence and that such information will not be divulged to any third parties, unless explicit consent has been given to do so.
I consent to Queen Margaret staff and learners knowing what capacity my involvement is, what organisation I am from and what third sector, health and/or social care services I use/ have used.
I understand that it is my responsibility to provide prior notification, if I am unable to participate in the agreed involvement activity/activities, because of a change in my health status or personal circumstance, by contacting us on 0131 474 0000, or emailing the named QMU staff member linked to your involvement activity.

1. General Consent

By completing this form, you are acknowledging that you have read and understood the general terms and conditions outlined above *

2. About You

Full Name* *

Address *

Postcode* *

Email *

Your Expertise and Experience - Your experience and knowledge of living with a particular condition, of being an informal carer, of having firsthand experience of a specific social issue or life transition, is vital to influencing the professional education of healthcare students at Queen Margaret University.

What firsthand knowledge and experience do you have, that could enhance student learning about people experiencing different health, social or carer issues, that could influence how we deliver our professional health programmes at Queen Margaret University?

* *

3. Emergency Contact (e.g. Carer/Guardian/Next of Kin). (We will always endeavour to seek your permission before contacting anyone. Sometimes this is not possible and in providing the details of this individual you are consenting to us contacting them in an emergency situation)

Name *

Relationship *

Emergency Contact Person's Email *

Emergency Contact Person's Telephone Number *

4. Access Needs - About You (please complete before you start your involvement activities to tell us about what you need to take part in your chosen activities with QMU)

If other, please provide more information on your preferred methos of contact with QMU

Other - please tell us what communication supports you require

If yes, will your support worker or personal assistant need anything?

If yes, will your assistance dog need anything?

If yes, please tell us about what you require (e.g. high back, arms, no arms)

Do you have any health conditions or other needs (e.g. diabetes, requiring regular breaks, susceptibility to seizures, etc.) that we should be made aware of to ensure your safety and well-being? *

If yes, and you need a parking space reserved, please tell us the registration of the vehicle you will be using

Is there anything else that you want to share about your needs and preferences whilst undertaking involvement activities with us? *

6. Signed By Representative

Signed by Representative - please provide name. Note: This is usually someone you have a pre-existing legal agreement with and who has been given advanced permission to sign documents on your behalf, perhaps due to a physical, sensory or cognitive impairment. If this does not apply to you, no action is needed here.