Informed Consent Form
 Instructions for Nursing Homes

Informed consent forms provided here are reviewed completely at least every two years.  In addition, the Department attempts to routinely update the forms for new medications, substantial changes in medication labeling, FDA approved uses and new warnings.  Online versions of the forms contain the most recent revision date at the top.  A blank from is downloadable, in the event that a form specific to a given medication is not available.  The blank form can be used along with the medication information available from many sources including the package insert, Physician's Desk Reference, FDA and many others.

It remains the responsibility of the facility to research and provide residents with the most current information.  Please make sure you are using the most updated form.  If a form is not available or it does not appear to be up to date please contact Doug Englebert (douglas.englebert@wi.gov).

Background

The informed consent forms that are being made available are multipurpose and designed to meet statute and administrative code requirements for a variety of facilities. The forms have been modified to contain the information now required by Wis. Stats. 50.08.

Finding the Appropriate Form

Informed consent for medications F-24277 Series medication forms are available as print-on-demand forms on the DHS Forms Library located at http://www.dhs.wisconsin.gov/forms1/F2/MedBrandName.htm. There are two indices available for locating appropriate medication forms. The first index is by 'Brand Name' and the second is by 'Generic Name' for medications.

Once the appropriate index is selected, in the upper left corner of the screen, select the Edit menu and from that menu, select 'Find on this Page'. Type in the medication name in the window and select the find button. This process will take you to the link for the appropriate form. Left click on the link and the informed consent form will open ready for use.

If you do not know the exact spelling of the medication, indices are listed in alphabetical order. You can scroll through an index until you find the desired medication. Click on the link to open the Informed Consent form.

Instructions for Use of Forms

Accessing and using print-on-demand forms requires that users have Adobe Acrobat software on their computer or network. Print-on-demand forms can be completed manually by means of hand writing or typing forms.

Introduction: This is the section to identify a resident.

Section 1: This section identifies the reason for and expected benefits of the medications.

Section 2 (Alternatives): This section is to identify potential other interventions. Many of the form identified alternatives will not apply to most nursing home residents. Remember, this form is used in many different types of facilities.

Section 3 (Consequences): This section is to identify consequences if a medication is not used. Many of the form identified consequences will not apply to nursing home residents.

Section 4: Side effects and risks of the medication.

Signature and Rights: The resident, guardian or Power of Attorney for Health Care (POA-HC) must read, understand and sign in this section. There is also a signature or initial line on each page that should be initialed to show the resident, guardian or POA-HC has received each page.

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Last Updated: October 11, 2011