Senior Mentor Information Intake Form

  • CONSENT AUTHORIZATION AND AGREEMENT TO PARTICIPATE IN THE SAGE PROGRAM

    PURPOSE

    The reason for a Seniors Assisting in Geriatric Education (SAGE) Program is to help acquaint the osteopathic health care and Interprofessional health professions’ students to a diverse population of older adults defined as those 60 years and up. It is our belief that this will help promote positive attitudes towards caring for older adults.
    All of the data obtain from this program will be collected for medical education evaluation and improvement. This is an education and training project funded by the Reynolds Foundation and UNT Health Science Center.
    The SAGE Program is conducted by the Division of Geriatrics Reynolds Interprofessional Geriatric Education & Training In Texas (IGET-IT) Program at the University of North Texas Health Science Center/TCOM in collaboration with Meals on Wheels of Tarrant County, Inc. (MOW).

    PROGRAM PROCEDURES

    Being a senior assisting in this geriatric education program means that you are volunteering to work with two to seven health care professions’ students for the first two years of their healthcare education experience, if you are willing and able. It also means that you agree to meet with students assigned to you in your home. As a senior mentor, health care professions’ students will ask to perform a limited physical assessment on you, as well as ask to obtain some medical and personal information about you. These assessments are not meant for diagnostic purposes. You will also be asked to complete study questionnaires and provide constructive as well as personal comments to the students. The health care profession’ students are not doctors or licensed health care professionals and will not be providing medical advice. If you have any questions about your health, please contact your primary healthcare physician.

    POTENTIAL RISKS

    There are minimal risks from participating in this program. There is potential for embarrassment for you due to the limited physical assessment; however, you have the option of declining the physical exam/assessment or requesting that a same sex student is present for your exam. There is a potential risk of a breach of confidentiality in which your program results may be accidentally revealed. However, program personnel will take all precautions necessary to protect your confidentiality. All of your health and personal information will remain confidential and will only be available to 6/4/2014 personnel overseeing the program. All information used for teaching or publication purposes will be kept strictly anonymous.

    POTENTIAL BENEFITS

    There are important benefits that the participants may obtain from taking part in this program. The benefits may include: (1) Home safety evaluation; (2) Blood pressure checks with each visit with information provided on a card to carry with you to your doctor; (3) Receive education on community resources; and (4) The analysis of the data collected from this program might provide a better insight in healthcare delivery to the elderly.

    CONTACTS

    If you wish any further information or have questions or concerns about this program, please contact Dr. Sandra Marquez-Hall at the UNT Health Science Center, Division of Geriatrics Reynolds Geriatric Education-In Texas (GET-IT) Program at (817) 735-2949. If you have any questions regarding the overall program evaluation part of this project, you may contact the Institutional Review Board, University of North Texas Health Science Center at Fort Worth at (817) 735-0409.

    LEAVING THE PROGRAM

    Your participation is completely voluntary. Should you decide not to participate, this will not be held against you in any way by UNTHSC, UNTHSC Health (if you are a patient), or any other agency used to recruit seniors for this program.

    CONSENT

    You agree to participate in the Seniors Assisting in Geriatric Education (SAGE) Program through UNTHSC. The nature and purpose of your participation have been fully explained to you, and you have had the chance to ask any questions you have about the program.

This page was last modified on February 15, 2019