INFORMED CONSENT
Staff Recipient
I, _____________________________________, agree to participate in the evidence-based
practice change doll therapy education program to decrease agitation in residents related to
dementia, which is being conducted by Jechell Lary-Waller, who can be reached at 478-390-
3836 or Jechell.larywaller@bobcats.gcsu.edu. I understand that my participation is voluntary; I
can withdraw my consent at any time. If I withdraw my consent, my data will not be used as part
of the evidence-based practice change and will be destroyed.
The following points have been explained to me:
1. The purpose of this evidence-based practice change is to utilize a non-invasive method to
curtail problem behaviors in residents with dementia through education using a pre and
posttest Likert Scale.
2. The procedures are as follows: you will be asked to participate in an educational in-
service related to practice change through doll therapy. You will be asked to participate
in a short pre and posttest evaluation survey to assess knowledge before and after
education. You will then be asked to observe the resident prior to and after receiving a
doll. You will then complete a pre and post-survey related to your findings.
3. Your name will not be connected to your data. Therefore, the information gathered will
be confidential.
4. You will be asked to sign two identical consent forms. You must return one form to the
investigator before the project begins, and you may keep the other consent form for your
records.
5. There are no questions that are intended to be invasive or personal. If you become
uncomfortable answering any questions, you may cease participation at that time.
6. This project is being conducted because of its potential benefits, either to individuals or
to humans in general. The expected benefits of this evidence-based practice change
include the development of practice guidelines to implement and evaluate doll therapy in
long term care facilities. The practice change will also determine the feasibility of doll
therapy to decrease aggressive, stressful moments for the resident.
7. You are not likely to experience physical, psychological, social, or legal risks beyond
those ordinarily encountered in daily life or during the performance of routine
examinations or tests by participating in this project.
8. Your individual responses will be confidential and will not be released in any
individually identifiable form without your prior consent unless required by law.
9. The investigator will answer any further questions about the project should you have
them now or in the future (see above contact information).
10. In addition to the above, further information, including a full explanation of the purpose
of this evidence-based practice change, will be provided at the completion of the project
on request.
11. By signing and returning this form, you are acknowledging that you are 18 years of age
or older.
