Report on the Needs Assessment

Appendix 3: Informed Consent Form

The Informed Consent Form, used to recruit individual interview and focus group participants, was approved by the Research and Ethics Committee of the Montreal General Hospital, MUHC.

Informed Consent Form

Study Title:

Health Education Project: Needs Assessment


  1. Linda Shohet, Principal investigator, Director, The Centre for Literacy of Québec
  2. Denise Malo, Co-investigator, Montreal General Hospital
  3. Odette Langlais, Principal researcher

Health Canada has provided financial support for this project.

The Study:
We are a doing a study to improve health education for patients at the Montreal General Hospital. We would like to invite you to participate in this study. Your ideas about the kind of health information that is given to patients will be very helpful to us. You can help us understand how we can improve health education for patients.

This is a project of the Montreal General Hospital and The Centre for Literacy of Québec. To improve patient education at the hospital, we want to set up a Health Education Centre. This Centre will inform patients and their families about their health and healthcare. It will:

  1. Give information and all kinds of classes and teaching for patients and their families;
  2. Help health care workers communicate better with patients;
  3. Collect and give out information and findings about health education.

The first phase of the project is the Needs Assessment. Three units in the hospital are participating: Dialysis, Pre-op Centre and Oncology Hematology. We want to ask patients, caregivers, health care workers and support staff about the health education needs of patients. We also want to ask health care workers what are their needs as educators.

Your Participation:
You are completely free to participate or not. If you refuse to participate or decide to leave the study, this will not affect in any way your health care or your benefits. We invite you to participate in:

  1. An individual interview. You will spend about 30 minutes with the researcher (only once). They will ask you about what you need in terms of health information and health education. They will write down the answers.


  • A small-group discussion of about one hour. You will discuss patient health education with others.

All your answers to the questions and what you say during the discussion is strictly confidential. We will not write down your name on the questionnaire. We will keep records in a safe location. The researcher will ask you questions and collect information. He or she will not be able to help you with your current health needs. If information is given to the researcher that should be communicated to the health care worker (important information for the patient's health), then verbal consent will be obtained from the patient or the caregiver to communicate this to the health worker. The Research Ethic Committee of the Montreal General Hospital may look at research records from this study. This is to verify that the research is done in agreement with Montreal General Hospital and the Montreal General Hospital Research regulations for research involving humans.

Risks and Potential Benefits
There are no foreseen risks for you to participate in this study. There are no immediate benefits either. However, we hope to improve the way information is provided to patients at the hospital in the medium to long term.

There is no compensation offered for your participation in this study.

Contact Persons
If you have questions about your rights as a participant in this study, please contact Mr. Glen Fash, the Representative of the Patient's Committee at (514) 937-6011, ext.2409. If you have any questions regarding your participation in this research study, you should contact Linda Shohet, principal investigator, Director, Centre for Literacy of Québec at (514) 931-8731, ext.1411; Denise Malo, co-investigator, Montreal General Hospital at (514) 937-6011, ext.4183; or Odette Langlais, principal researcher, at (819) 827-9124.

A Steering Committee looks after this project. It is composed of hospital staff, patient representatives, the Director of The Centre for Literacy and a person from Health Canada. The Steering Committee has hired two researchers to do the Needs Assessment: Odette Langlais and Charles Draper.

I understand the information in this form.
I was able to ask questions and I am satisfied with the answers.
I agree to participate in the Needs Assessment.
I have been given a signed copy of the consent form.
I do not give up any of my legal rights by signing this form.

Signed by Participant Print name
____________________________ ________________________
Signed by Researcher Print name
____________________________ ________________________
Signed by Witness/Translator Print name
____________________________ ________________________

Date: ____________________________