Hearing School Screening

Parental Consent Form 

Please fill out the following form if you consent to your child participating in our Hearing Screening School programme.

I have read, or have had read to me in my first language, and I understand the Participant Information Sheet
I have been given enough time to consider whether or not to participate in this study
I have had the opportunity to use a legal representative, whanau/ family support or a friend to help me ask questions and understand the study
I am satisfied with the answers I have been given regarding the study and I have a copy of this consent form and information sheet
I understand that taking part in this study is voluntary (my choice) and that I, or my child, may withdraw from the study at any time without this affecting my medical care.
I consent to the research staff collecting and processing my child’s information, including information about their health.
If I, or my child, decide(s) to withdraw from the study, I agree that the information collected about my child up to the point when I, or my child, withdraw(s) may continue to be processed within the limitations of the privacy policy of the National Foundation for Deaf and Hard of Hearing.
I consent to my child’s GP or current provider being informed about their participation in the study and of any significant abnormal results obtained during the study.
I agree to an approved auditor appointed by the New Zealand Health and Disability Ethic Committees, or any relevant regulatory authority or their approved representative reviewing my child’s relevant medical records for the sole purpose of checking the accuracy of the information recorded for the study.
I understand that my, and my child’s, participation in this study is confidential and that no material which could identify them personally, will be used in any reports on this study.
I understand that only the researchers, my child, myself and anyone that my child or I authorise can access any personal information held about myself or my child (including outcomes of the study and responses to questionnaires) as per the privacy policy of the Foundation for Deaf and Hard of Hearing.
If hearing loss is detected, I agree that the results will be shared with the school to ensure they can provide appropriate support. The school will share the results with me.
I know who to contact if I have any questions about the study in general.
I understand the compensation provisions in case of injury during the study.
I understand my responsibilities as (the parent/guardian of) a study participant.
I wish to receive a summary of the results from the study.
Declaration by Parent/Guardian:

Your Signature

(Use your finger or computer mouse)

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Address: Level 1, 149-155 Parnell Road, Auckland 

PO Box 37729 Parnell, Auckland 1151, New Zealand

Phone: 09 307 2922 or 0800 867 446 

Email: Lorien.Doherty@nfd.org.nz

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