Informed Consent Form

Note for Suffolk GP Federation Staff

This form should only be used for activities outside of the named categories

In giving Suffolk GP Federation permission to use your material (photograph/case study) you
are supporting the vital work the organisation does. If you would like a copy of anything your
material is used in please request one and we will send it to you. Thank you.
Name of person
giving consent:
Age
If the person giving YES ☐ NO ☐
consent is an adult
(over 18 in England, If NO please explain why:
Northern Ireland and
wales and over 16 in
Scotland) are they
able to consent in
their own right:
Age – if under 18:
Address:
Telephone:
Type of material:

I give Suffolk GP Federation the right to use the material named above.
I understand that my material will become part of Suffolk GP Federation’s library and/or
media store and may be used in/on (description of use to be inserted by staff):

I understand that my material will be stored and used for up to three years from today’s date,
unless otherwise specified below.
Restrictions and comments
If you want your material to be stored for less than three years, or if you have any other
restrictions or comments, please indicate below:

Document number: #014 Page 1 of 3 Policy issued: March 2014

Version 1.0 31st March 2014 To be reviewed before: August 2014
Please check the shared drive for latest versions as this document may be subject to change throughout the year
Agreements
This permission form has been
explained to me by (a member
of Suffolk GP Federation staff):
Signature of person giving
consent:

Name of parent/guardian:
Signature of parent/guardian:

Date:

Suffolk GP Federation use only

This form is part of Suffolk GP Federation’s Informed Consent Policy.
Batch/reference no:
Project name:
Contact person:
Telephone:
Suffolk GP Federation Service
manager signature:
Date:
XXX signature

Date:
Other signatures required by
plan signature

Date:
Other signatures required by
plan signature

Date:

Document number: #014 Page 2 of 3 Policy issued: March 2014

Version 1.0 31st March 2014 To be reviewed before: August 2014
Please check the shared drive for latest versions as this document may be subject to change throughout the year
Other signatures required by
plan signature

Date

Notes
The subject is the person who appears in the photograph/case
All references to Suffolk GP Federation in this form include a reference to any successor of
Suffolk GP Federation.
If the subject is under 18, their parent/guardian should also sign the form.

Document number: #014 Page 3 of 3 Policy issued: March 2014

Version 1.0 31st March 2014 To be reviewed before: August 2014
Please check the shared drive for latest versions as this document may be subject to change throughout the year