Form K-905-2759 Acknowledgement And Certificate Of Completion Of Medical Consent Training printable pdf download

Form K-905-2759 Acknowledgement And Certificate Of Completion Of Medical Consent Training

Form K-905-2759

Revised November 2013

CKNOWLEDGEMENT AND

ERTIFICATE OF

OMPLETION OF

EDICAL

ONSENT

RAINING

–

HILD PROTECTIVE SERVICES

MEDICAL SERVICES

Purpose: Use this form to document completion of initial (pre-service for licensed residential operations)

and annual training by the medical consenter (includes primary or backup) on the responsibilities of

Medical Consent for children and youth in DFPS conservatorship.

Directions: After completing medical consent training and signing this form, the medical consenter

provides a signed copy to the child's primary caseworker at the time the medical consenter is being

designated for a child. The CPS caseworker files a copy of the signed form in the child's section of the

case file. For questions about this form or assistance with its completion, please contact the CPS

caseworker for the child, your agency case manager or the DFPS Medical Consent mailbox at:

Medical.Consenter@dfps.state.tx.us

I ___________________________________________________ acknowledge that I

Medical Consenter (print name)



have received the DFPS approved Medical Consent training,



understand the principles of informed consent for all types of healthcare, and



understand the principles of informed consent for psychotropic medications, and that

non-pharmacological interventions should be considered and discussed with the

prescribing practitioner before consenting to the use of a psychotropic medication.

Signature – Medical Consenter

Date Signed

CERTIFICATE OF COMPLETION

This certifies that ______________________________ has completed a two and a half hour

(Medical Consenter)

Caregiver Medical Consent Training

Caseworker Medical Consent Training

on _____________ (date).

Issued by ________________________________________________________________

(DFPS Staff or Residential Child Care Provider)

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Form K-905-2759 Acknowledgement And Certificate Of Completion Of Medical Consent Training