CONSENT TO PARTICIPATE IN GOUVERNEUR RESCUE’S RURAL EMS TRAINING PROGRAM

Informed Consent

Title: SAMHSA Rural Emergency Medical Services Training-Grant #1H79TI084706-01

Program Description: This program is being conducted by Gouverneur Rescue, a private nonprofit EMS provider located in St. Lawrence County, NY on behalf of the Substance Abuse and Mental Services Administration (SAMHSA). The purpose of this program is to recruit and train Emergency Medical Services Personnel in rural areas of St. Lawrence County. This program includes: EMT offered in person and through distance learning, Employee Skills Training and Continuing Education for paid and volunteer EMS professionals through Con Ed Program.

Participant Selection:

Gouverneur Rescue is an Equal Opportunity Employer and strong advocate of workforce diversity. Minority/Female/Sexual Orientation/Gender Identity/Disability/Veteran. You are being asked to participate in this program because you have enrolled in an EMT, Regional Skills Training, or ConEd program offered through Gouverneur Rescue. Throughout these programs you will be asked to complete pre/post tests, as well as course evaluation forms. The classes will take place at designated training locations throughout St. Lawrence County.

For EMT Course: Participants must be 17 years of age. Be fluent in the English language.

Risks and Benefits: Emergency Medical Services (EMS) personnel treat patients that have complicated medical or traumatic conditions that require considerable knowledge, skill, and judgment to be treated effectively in the out-of-hospital setting. Some are critically ill or injured, and the proper care can make the difference between life and death. While other’s situations may not be a matter of life or death, it is no less significant to them and their family. High quality out of hospital emergency care is an important part of the health care system. Participation in these programs will increase the participants ability to provide safe and effective out of hospital, emergency care through the EM Competency certification and skill and competency review.

One risk associated with this program; may be the discomfort some people feel when answering questions on course evaluation. However, you do not have to respond to all questions if you do not want to.

A second risk may be injury as a result of your participation in a training activity. Gouverneur Rescue Instructors and Site Monitors will inspect the classroom and skills labs to ensure they are tidy, and no injury hazards exist. If an injury occurs the participant will be directed and/or assisted to medical treatment. Gouverneur Rescue Instructors and Site Monitors will document the injury per Policy:

Pathogen exposure risk. All facilities will adhere to CDC and NY DOH recommendations as it pertains to pathogen exposure. Participants will utilize Personal Protective Equipment as needed. Weather related risks include severe thunderstorm, tornado, winter storm, or blizzards. Instructors and site monitors will inform students of facilities steps for severe weather including identification of safe locations within the training location should the event escalate, classes cancelled or rescheduled or hosted in different locations based on weather conditions. In the case of a winter storm or blizzard, grounds will be maintained by clearing paths and ensuring safe egress and ingress to the facilities or based on local recommendations class rescheduled based on the conditions. Facility related risks include electrical failure, water failure, sewer failure, or fire hazard. Instructors and site monitors will consider hosting the class in a different location. In the case of electrical failure, backup generators would kick in. In the case of fire, participants will be made aware of exits and procedures in case of fire. If immediate fix or alternate location is not available class may be rescheduled. Another risk may be that the information you give us would not be kept private. We describe in the section “Privacy” below our procedures. If there is anything that bothers you about the class/programs, the persons listed below will be glad to talk about it with you.

Collection of Personal Information: You may be required to provide certain personal information when you elect to participate in one of the classes listed above. This may include a) registering for a class b) sending us an email message c) submitting your credit card or payment information when registering for a class. To wit, we will use your information for, but not limited to communicating with you in relation to programs you have requested. For EMT Course work participants must provide proof of immunizations against Mumps, Rubella, Rubeola, Varicella Zoster and Hepatitis B. As well as provide proof of receiving Tdap vaccine, 2 Step PPD, and Influenza Vaccine.

Privacy: Any information obtained from you during these training programs will be kept as private as possible, to the extent of the law. We will not share this information with others. Information will be kept in Monitor Signature locked files and only staff members connected with this project will have access to it. Forms with personal information that could be used to identify you will be kept in locked files in a locked room. The information we gather will be used only in reports in summary form. Your name will never be used unless you sign a separate form giving your permission.

Right to Withdraw: You may refuse to participate in these training programs, and you may stop participating at any time.

Voluntary Consent: All of the above has been explained to me and all of my current questions have been answered. I understand that I am encouraged to ask questions about any aspect of this program during the course of this grant program period, and that such future questions will be answered by the project director, Melissa A. Brook from Gouverneur Rescue I understand that I am participating in a course or program that is funded in part by the Department of Health and Human Services Substance Abuse and Mental Health Services Administration, FY 2021 Rural Emergency Medical Services Training Grant.

I understand that I am participating voluntarily and that there will be no penalty or loss of benefits for not participating. I understand that activities included in this program may be educational intervention, surveys, course evaluations and self-reports.