The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Registration

Returning?

A A A

TRAINING MODULE ONLY

DO NOT ENTER REAL DATA HERE

Ensure you have obtained and recorded (in your records) the participant's CONSENT to share their personal information (name, email address and funding information on this form) with a third party (GLA:D® Australia).

DO NOT REGISTER THE PERSON IF:

They are already registered - email GLAD.Australia@latrobe.edu.au with any amendments or issues, or if unsure. AVOID DUPLICATE REGISTRATIONS - they are frustrating for participants and generate data issues.
They have already started their education and education sessions - baseline questionnaires must be sent prior to commencement. If unsure (eg one education session completed) please register ASAP and email GLA:D Australia to let us know.
They are not planning to complete the full program (all exercise and education sessions) (it's ok if something happens and they don't - this will be picked up in the 3 month questionnaire). They must intend to complete the full program though.
They are still within 12 months of a previous registration (check with GLA:D Australia if unsure)

WHAT HAPPENS IF:

If you enter your email correctly, and fully complete the registration, you will receive a confirmation email. This will show the email address that the questionnaires have been automatically sent to.
If the registration is not fully completed it will be saved but the questionnaires will not be sent.
If you select Save and Return Later, it will be saved but the questionnaires will not be sent.
If you save an incomplete registration, please contact us to update the information rather than completing a new registration.
If the recipient email address is correct in the confirmation email, the intended recipient needs to check all junk and spam folders. Resending will simply travel the same path.

Today's Date

* must provide value

D-M-Y

Participant's first name and last name

* must provide value

Intended method of program delivery

* must provide value

Group (on-site)

Group (telerehab)

Individual (on-site)

Individual (telerehab)

Monitored home program

Combination of methods

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Clinicians may now be looking at more diverse ways of providing GLA:D®. Please tell us the agreed plan for delivery on the program at the moment. It doesn't matter if you have to change part-way through - we will find that out at the follow-up survey at 3 months. Any plan that meets the minimum criteria (x12 60-minute exercise sessions over 6 weeks, x2 education sessions 60-90 minutes each, data collection at baseline/3 months/12 months) is acceptable, as long as it best fits the needs of the participant in the context of what the clinic is able to offer.

Briefly describe combination

* must provide value

Participant Information and Consent sheet

Participants completing online questionnaires will see and read this online. This does not need to be returned to GLA:D® Australia. However, you may wish to have a printed copy for people to read or take with them.

Attachment:GLAD Participant Information Sheet Version 3.0_24 July 2023.pdf

Survey method

Please note we will no longer be collecting paper questionnaires.

Please consider using a clinic's email address by selecting "online questionnaires sent to clinician".

If online questionnaires are not possible at all, please still register the participant and select the final option.

* must provide value

Online questionnaires sent to participant

Online questionnaires sent to clinician

Participant is unable to complete online data collection. Outcome measurement and evaluation will occur internally.

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E-mail address that will receive questionnaires

* must provide value

Date to send questionnaires.

Use this to postpone the sending of questionnaires (i.e. if there will be a significant delay to starting the program).

Ensure this date is PRIOR to commencing GLA:D Sessions.

If you don't need to postpone, select TODAY.

DO NOT BACKDATE. If you have forgotten to register someone, backdating will not fix this. Email GLA:D Australia instead.

This date becomes the Baseline Date. 3-month and 12-month follow-up questionnaires are sent based on this date.

* must provide value

D-M-Y

Clinician name

* must provide value

Clinician's email address

* must provide value

Clinic

* must provide value

Is this person being funded for GLA:D as a Chronic Disease Management Program (CDMP) through their Private Health Insurance (Hospital Cover)?

Please note that this will only be available for eligible members completing the program through clinics who have set up agreements with the relevant PHI.

**Please note: This DOES NOT refer to Enhanced Primary Care through Medicare (public funding) or to claims made through private health extras.**

* must provide value

Yes

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Which Private Health Insurance?

* must provide value

Which other PHI?

* must provide value

Please print out and provide the following Patient Information Sheet and Consent Form to the participant

Please go to https://gladaustralia.com.au/cdmp-guide/ for instructions and guidance to complete this correctly.

Attachment:PICF_for_PHI.pdf

You can play this audio file to help you explain CDMP consent if you wish.

Ensure that the signed consent form is completed, including:

Participant ticking relevant boxes for sharing information with their private health insurer, and for future projects, as applicable.
Participant signing and dating their signature
Clinician checking the boxes to say they have explained the consent and answered any questions, and that they are qualified to do so
Clinician signing and dating their signature
Providing a signed copy to the participant
Ticking the box on both copies to say that a signed copy has been provided to the participant

Do you have a fully signed, completed CDMP Consent form ready to upload?

If you do not have the form ready to upload, but the participant is ready to start the program, you can reply 'No', then continue with this registration and email the form through ASAP to glad.australia@latrobe.edu.au.

If you do not have the form ready to upload, and the participant is NOT ready to start the program, please exit this registration without saving, and create a new registration when this situation has changed.

* must provide value

Yes

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Please upload a scanned version or a photo of the Consent Form Signed by the participant.
(note that you only need to upload here the signed page 6 of the Patient Information Sheet and Consent Form)

**This consent is specifically about whether the participant consents to information collected by GLA:D Australia being shared with their Private Health Insurer. If they wish to decline consent to providing any information at all to the program, they must follow the link within the invitation email to decline consent as the first question in the baseline questionnaire (the same as any other participant).**

DO NOT ATTACH WITHDRAWAL OF CONSENT FORMS HERE

* must provide value

Upload file

Please ensure you complete a treatment plan with the client

(Note that you do not need to upload or send this document to us, but you need to keep a completed version at your clinic)

Clinic setting
(Please select the option that best describes the clinic setting)

* must provide value

Private clinic

Public hospital

Private hospital

Community health

Aged care

Sporting facility

Other (please specify below)

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Please specify setting

* must provide value

Yes

Is this person claiming through private insurance?

* must provide value

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Is this person accessing public funding?

* must provide value

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Is this person paying out of pocket?

* must provide value

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Is this person being funded by a compensable body other than a private health insurer (e.g. Workers' Compensation Scheme, Road Traffic Injury Insurance Scheme, NDIS etc.)?

* must provide value

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Incorrect Email address

Clinician contacted

No response from clinician

Emails ceased

Record data deleted due to

Duplicate record

Change in diagnosis/inclusion criteria

Request from participant to remove all data (not merely withdrawal of consent)

Other

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Private Health Consent form details:

Form attached and completed correctly

Copy provided to participant

Consent to share with PHI

Consent to use data for related studies

Clinician contacted for correction

Incomplete or issues persist but no further follow up planned

Researcher comment

Expand

La Trobe Ethics: HEC21303

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