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 (firstname.lastname@example.org).
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