Explicit Consent for ECLIPSE Primary Care Data Processing - the TIMES Study

Practice Pro-Forma

We are grateful that your practice has agreed to take part in the TIMES research study to enhance dementia care.

Project overview:

The TIMES Study (NIHR 202345) is an NIHR-funded cluster randomised controlled trial to determine the clinical, social and cost effectiveness of a decision support tool to optimise community-based tailored management of sleep (TIMES) for people living with dementia or mild cognitive impairment and sleep disturbance.

The fully authorised TIMES study protocol describes research activity for the TIMES study. The ECLIPSE data processing impact assessment (DPIA) describes ECLIPSE data processing activity for the study. With your explicit instruction ECLIPSE will provide secure data processing services for the TIMES study on your behalf in accordance with the protocol, DPIA and our existing data processing contract (DPC).

In brief: ECLIPSE will register practice staff that the TIMES team identify to them, as ECLIPSE users for your practice; identify and provide patient participants with study information and questionnaires; conduct secure data processing activity; and ensure that patients who wish to take part in TIMES are supported to do so.

The NIHR Research Delivery Network (RDN) has indicated to ECLIPSE that your practice has consented to take part in the TIMES study feasibility trial. Please complete the details below to instruct ECLIPSE to act on your behalf.

Name of individual completing the form:
First Name

Last Name

Position:

NHS Email

Name of your GP Surgery:

National Practice Code: (optional)

Practice Admin Lead:
First Name

Last Name

NHS Email:

Do you give permission for patients within the defined cohorts to be contacted by the ECLIPSE automated patient engagement interface? (NB: this will involve SMS messaging):
Yes

No

Do you give permission for patients within the defined cohorts to be contacted by the ECLIPSE patient engagement team? (NB: this will involve telephone calls):
Yes

No

Do you give permission for patient engagement, data processing and data sharing by ECLIPSE for the purposes of the TIMES study as described in the TIMES study protocol and DPIA?
Yes

Do you give permission for staff registration to ECLIPSE services for your practice for the purposes of the TIMES study as described in the TIMES study protocol and DPIA?
Yes

I confirm that I am authorised to instruct ECLIPSE to process practice data for the purposes described.
Yes

Name:

Date
MM

DD

YYYY

Thank you for agreeing to the Explicit Consent for the TIMES/ECLIPSE Primary Care Data Processing Study.