Pediatric Physical Therapy Course Participant Informed Consent and Liability Waiver for Telehealth Video Teaching

Telehealth is a delivery model for providing health-related services at a distance using telecommunication technology. Telehealth can encompass many aspects of therapy services including evaluation, intervention, monitoring and education. Delivering therapy services through telecommunication technologies allows access to care and services wherever the patient is located, thereby removing barriers to care and promoting intervention approaches within the natural context and environment. This can influence performance and engagement of activities and affect health and wellness, participation, prevention, and improved quality of life. The UAB DPT Program is committed to teaching its students the value of telehealth therapy.

This form is for the child and parent/caregiver to understand the benefits and potential risks of participating in a live video educational session with DPT students.

By signing below, I understand the following benefits of a video educational session:

• Avoiding the need to travel to participate in the educational session.
• The child and parent can remain in their natural environment for the educational session.

By signing below, I understand the following risks of video educational sessions:

• Potential lapses in sound or picture transmission can impede the educational encounter.
• Despite efforts to protect patient privacy and confidentiality, breaches may occur such as the possibility of third-party presence. Physical Therapists typically perform video therapy sessions in a private room and we ask volunteers to do the same (parents/caregivers may be present for video therapy).
• Technology may affect the reliability of assessments when performing client evaluations using telehealth delivery methods.

By signing below, I understand the following:

• I understand that the laws protecting patient privacy and confidentiality of medical information also apply to the UAB DPT Program’s Telehealth video educational sessions.
• I understand that I must currently be in the state of Alabama to participate in the UAB DPT Program video Telehealth Educational Session.
• I understand that I have the right to refuse or terminate the Telehealth video educational session at any time, without affecting my right to future care or treatment at UAB.
• I understand that my participation in the UAB DPT Program’s Telehealth Video Educational Session is voluntary and I will not be paid for participation.

By submitting this form, I attest that I have read and understand this Informed Consent Form for The UAB DPT Program’s Telehealth Video Educational Session and I consent to my child’s participation.

Waiver of Liability

• I consent to have my child participate in the Department of Physical Therapy Pediatric Assessment and Treatment Labs. I understand that my child will be participating with Department of Physical Therapy faculty and Doctor of Physical Therapy Students. The DPT students under faculty supervision will instruct my child (via live video) to perform typical movement and play activities. The students will be directly supervised by Dept. of Physical Therapy faculty who are also licensed physical therapists.
• In consideration of my consent for my child to participate in this activity, I, the undersigned (participant), for myself, my family, next-of-kin, guardians, heirs, administrators, personal representatives, successors and assigns hereby agree to release, discharge, indemnify, and hold harmless the Board of Trustees of the University of Alabama, whether or not acting as the Department of Physical Therapy or faculty or DPT students (University of Alabama Heersink School of Medicine, the planning committee, any sponsors, charitable beneficiaries, and site owners, including any officer, director, employee, or volunteer of any of the person(s) or entity listed above including their affiliates, agents, trustees, fiduciaries, representatives, successors, and assigns) (“Indemnified Parties”) from any and all claims, demands, cost, liability, or damages arising out of or related in any way to my child’s participation/activities in this activity, whether or not such claim, demand, costs, liability or damage results in part or otherwise from the negligence of any of the Indemnified Parties.
• I warrant and represent by my consent for my child to participate in this activity, that my child’s physical condition is adequate to participate safely in the activity and that the Indemnified Parties have no obligation to provide or pay for my child’s care and have not undertaken the responsibility to do so should ( I) my child become injured. I hereby consent to any and all treatment resulting from injury and acknowledge that I am solely responsible for the cost of such treatment.
• I authorize and consent to, whether by videotape, file, newsprint, written advertisement, or otherwise, of any materials containing my child’s name or picture and I release any of the Indemnified Parties and all persons acting under their authority from any claims I might have due to initial or subsequent publication of any such materials or photographs. I hereby certify have fully read and understand for forgoing release, waiver and covenant not to sue, and sign it voluntarily.