Hounslow Safeguarding Adults Online Consent Form

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Healthwatch Hounslow are coordinating and facilitating a Safeguarding user forum to ensure feedback can align with and feed into the Quality Assurance reporting schedule. Give your permission to take part in the Hounslow Safeguarding Adults Forum. Please make sure you have read the information before completing this Consent Form

If you would like to join us to talk about your safeguarding experiences, we need your permission. If you are happy to take part, please tick the Yes box. If you have any questions or would like to know more, please contact viviane@healthwatchhounslow.co.uk.

I have read and understood the information about this project provided on https://www.healthwatchhounslow.co.uk/safeguarding-adults-forum.

Yes

I know that I do not have to take part.

Yes

I know I can refuse to answer questions if I want or leave at any time. If I decide to do that, then any information I have already given will not be used or shared and will be destroyed straight away.

Yes

I agree that my information can be used in the report given to Hounslow Council – but it won’t say my name.

Yes

I understand that any personal information that can identify me will not be shared beyond the project team.

Yes

If I say something that is putting myself or someone else in danger, I understand this may have to be reported.

Yes

I agree to take part in this project and to be contacted by Healthwatch Hounslow.

Yes

Would you prefer?

Regular group meetings

Regular online meetings

Face to face interviews

Telephone interview

Questionnaire

Other (please specify):

This is required

Your name

Your telephone number

Your email address (if you have one)

Your experience

You have experienced safeguarding yourself

You are a Carer / Family / Friend