Informed Consent

The Fraser Health PQI Training - Consent for Collection, Use and Storage of Participant Information
As physicians/employees of Fraser Health, you have been invited to fill out the PQI intake form administered by PQI department.
Your personal information collected by Fraser Health is subject to protections under the BC Freedom of Information and Protection of Privacy Act (FIPPA).

To participate in this PQI Training Program, you are being asked to consent to enter the following information for use by Fraser Health:
  • Your name, MSP number, phone number, email, department, site, job title are used to track participant’s demographic information. This information is used to create summary stats/charts to evaluate our training volume and our delivery services

  • For the physician group, MSP identification is used for invoicing purposes to compensate for their time.

Access to entered information is limited to Fraser Health PQI employee, Janice Eng. At no point in time will your information be disclosed for purposes other than program evaluation as it relates to FH providing these services.

The information you choose to provide will be stored by Survey Monkey, a service provider located in the United States (US) of America, and will therefore be subject to US law. Your information will only be accessed by the PQI administrator and will be
protected by Survey Monkey in compliance with their Privacy Policy and Terms of Use. The electronic copy of the Survey Monkey results will be stored on the FHA M drive and then deleted from the Survey Monkey database.

Participation in the PQI Training Program is voluntary. There will be no
consequences to you if you choose not to participate. You may withdraw from this form at any time by submitting a written request to PhysicianQI@Fraserhealth.ca and in doing so your personal information will be deleted.

Questions about your information and this intake form may be directed to the Survey Administrator: PhysicianQI@Fraserhealth.ca.

Question Title

* 1. Consent: I have read and understood the Consent for Collection, Storage and Use of Participant Information.

I voluntarily consent to Fraser Health collecting, using and disclosing the information I provide as a participant in this survey. I further consent to the storage of my survey responses by Survey Monkey for an undetermined time period in the United States of America.

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