Appendix D: Consent Form for Classroom, Laboratory and Fieldwork Experiences
Department of Occupational Therapy
Entry-level Doctor of Occupational Therapy Program
Consent form for Classroom, Laboratory, and Fieldwork Experiences
As an occupational therapy student, you must learn to evaluate and treat a variety of conditions as well as participate in health promotion. Techniques involved in this endeavor are largely “hands-on” or involve the use of machinery and thermal agents. To assure your competence, you will be asked to practice various hands-on techniques and use various pieces of equipment safely. These skills will be practiced on you by other students in your class who have varying levels of competency, as well as by you on other students. In addition, your learning entails the dissection of a human cadaver.
Types of activities students will be expected to perform: Treatment and examination techniques may involve palpation for anatomical structures, resistance to muscle contraction, stretching and compressing of anatomical structures, mobilization of joint and soft tissue structures, assistive exercises, positioning, mobility and transfer techniques, and other active body movements such as gait training, stair climbing, and aerobic exercise. Use of machinery, mechanical devices, and thermal agents includes, but is not limited to, the use of mechanical traction, therapeutic electrical stimulation devices, hot packs, ice, and ultrasound. In splinting, you will use boiling water and heat guns to mold thermoplastic orthotics. In human dissection, you will use sharp scalpels and bone saws.
Potential risks: While the laboratory environment will be controlled to minimize risks, the following potential risks are rare but possible: In having the above techniques practiced on you, or in performing the techniques on other students, you may experience muscle soreness, strain, sprains, tearing of connective tissue, syncope or falls, allergic reactions, burns, cuts, infections, and their sequelae. In having electrical and thermal agents applied to you, you may experience slight electrical shocks, burns, or frostbite. In the dissection labs, you may cut yourself with the scalpel or bone saw.
Potential benefits: In practicing the skills required of a licensed occupational therapist in a supportive and educational setting, you will be prepared to effectively, efficiently, and safely evaluate and treat patients. In having the skills practiced on you, you will gain an appreciation of the experiences of actual patients.
Methods used to reduce the potential risks: In all scheduled learning formats and environments you will have faculty members and lab instructors as teachers and facilitators to instruct you and correct you in the required skills. Their instruction will include the precautions, contraindications, and safe application of the techniques they will teach you. In all cases, the environment of any lab will be controlled to minimize risks, and faculty will indicate the appropriate use of any protective equipment. Faculty will be aware of and carry out any necessary emergency procedures. At times, students may choose to practice lab techniques outside of scheduled class times without faculty supervision. This situation may increase the chance of the risks outlined. You are not permitted to use electrical or deep thermal modalities without the direct supervision of a licensed occupational therapist.
You will be asked to disclose in confidence any conditions which may increase the risks described above or prevent you from fully participating as a provider or receiver of the activities that are part of your student experience.
During fieldwork laboratory sessions, you are not permitted to practice techniques on a fellow student who has a known actual problem or condition for which occupational therapy may be a recommended treatment.
Fieldwork Education: I understand that I will participate in the process of fieldwork assignments, as delineated in the Occupational Therapy Program Manual. Fieldwork education assignments are made with student input and are based on student learning needs and availability of appropriate fieldwork sites. The Director of Clinical Education will decide final assignments for all fieldwork experiences. I will participate in the experiences to which I am assigned. I understand that I am responsible for reviewing materials from my assigned sites, and for complying with all regulations of that facility, including required health history and certification, in a timely fashion.
The program will attempt to schedule assignments for part-time experiences to be within a reasonable traveling distance from the Institute but may not be accessible by public transportation. I understand that the Institute is not responsible for arranging my transportation to and from the Institute and to/from locations where my fieldwork education will be performed. I also understand and waive any liability for the Institute in connection with any such transportation and risks thereof. I shall be solely liable for any such risk and loses that arise from such transportation. Full-time experiences may require that I relocate for an extended period, 12-16 weeks for full-time experiences. I understand that I am responsible for my own health insurance, housing, transportation, and related costs (uniforms, lab coats, etc.) for all fieldwork education experiences.
Students’ rights: I understand that I have the right to refuse to participate in any situation in which I feel I am not safe, my health is jeopardized, or my religious or cultural beliefs are jeopardized. If I feel the environment is unsafe, I may request that the faculty member make reasonable modifications that will improve the safety of the environment. I also understand that course-grading requirements may include specific competencies in evaluation and treatment. Assuming that I have no condition that would prevent me from fully participating in the role of a patient or an occupational therapist, I understand that I will not be able to receive credit within the course for these experiences if I choose not to participate.
I understand that I may ask questions about the activities required within the curriculum at any time. If I have further questions about my participation in laboratory experiences, I can contact Regina F. Doherty, OTD, OTR/L, FAOTA, FNAP, Chair of the Department of Occupational Therapy at (617)643-7768 or my academic advisor. I have been given a copy of this consent form as part of my Program Manual in the Entry-Level Program in Occupational Therapy.
Injury Statement: I understand that in the event of an injury to me during any school activities, I will be assisted in finding appropriate medical care, which will be covered under the provisions of my health insurance policy. The MGH Institute of Health Professions is not responsible for the costs of health care associated with activities that are part of the educational program.
Disclosure: I have the following conditions which I believe may place me at increased risk for performing or receiving the various techniques performed during the student experience.
I understand my responsibilities and the potential risks and agree to participate in learning experiences as outlined above. It is my responsibility to address any questions or concerns I have to my advisor or to the appropriate faculty member. I understand that by signing this consent form I am not waiving any of my legal rights.
Signature Date
Name (Print)