Archive: Consent Form for Survey

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Nanaimo Regional General Hospital

2053-1200 Dufferin Cr. Nanaimo, BC V9S 2B7

Phone 250-739-5979 Fax 250-739-5983

Consent Form for Research Study

“Are you ready for an office code blue?

An online video to prepare for office emergencies”

Who is conducting the study?

Principal Investigator: Dr Kathryn King (Clinical Assistant Professor, Department of Family Practice, UBC Nanaimo Site Faculty Advisor) 250-739-5979

Co-Investigator: Dr Simon Moore (Resident, Department of Family Practice, UBC Nanaimo Site) 250-619-1116, or at

Why are we doing this study?

Previous studies indicate that many physician offices are not adequately prepared for emergencies that occur in their offices, and that such emergencies are not infrequent. The purpose of this study is to assess if an online video is helpful in preparing offices and their staff for emergencies.

What happens if you say, “Yes, I want to be in the study”?

You will click a link below, which will take you to a brief video and the survey. You will watch the video only (you will not be recorded). After watching the video, you may answer the questions in the survey. We will ask you general questions about the video content and format. The online survey should take less than 5 minutes to complete. Your participation is optional. You may choose to not answer any survey questions and/or withdraw your participation at any time without any penalty or consequence.

What will happen to the results of the surveys? Can you get a copy?

The results of this study will be reported in a residency program project and may also be published in journal articles and books. You are welcome to access the final results of the study, which will be published on the study website in or after May 2011, at

Is there any being in this study could be bad for you?

There is an extremely small risk that the data you provide in confidence could be compromised; this risk is minimized by using secure servers and at no time asking for your identifying information along with your survey results. You may experience feelings of anxiety during the video, especially if you are concerned that you do not know the content; this risk is minimized by teaching the content throughout the video, and by allowing you to pause or stop viewing the video at any time. The study will use up a few minutes of your time. You may contact the study staff at any time should you have concerns. There are no other known risks.

What are the benefits of participating?

Because the video is designed to be educational, you may learn about office emergency preparation. You will have access to the knowledge in the video, and you will have the opportunity to share the video with your colleagues as a resource, at no cost. You will be contributing to the research on office emergencies, and others in the future may be helped by your participation. Finally, if you are a member of the College of Family Practitioners of Canada, you may receive continuing medical education credits (Mainpro-C) if you complete a “Linking Learning to Practice” reflective exercise after watching the video.

How will your confidentiality be maintained?

By taking part in this survey, your anonymity will not be compromised. This online survey company is hosted by Google Canada, a websurvey company which has locations in the Canada and the USA and as such is subject to Canadian and U.S. laws; in particular, the U.S. Patriot Act which allows authorities access to the records of internet service providers. This survey does not ask for personal identifiers or any information that may be used to identify you. The websurvey company servers record incoming IP addresses of the computer that you use to access the survey, but no connection is made between your data and your computer’s IP address. If you choose to participate in the survey, you understand that your responses to the survey questions may be stored and accessed in Canada or the USA. The security and privacy policy for the websurvey company can be found at the following link: No data will be stored on the survey website (i.e. at

Should you choose to enrol in the prize draw, you may choose to voluntarily provide your e-mail address via e-mail following the survey. Your e-mail address will not be requested or collected with your survey results. No attempt will be made to correlate your e-mail address with your survey response, and you are welcome to provide your e-mail address on any day following the completion of the survey, as long as the study period is still open.

As we do not collect identifying information, we will unfortunately not be able to remove your responses from the data set once they have been submitted. Information that discloses your identity will not be released without your consent unless required by law. All data will be kept on secure servers and/or locked filing cabinets at a University of British Columbia site, and destroyed after 5 years, in accordance with UBC policy.

Will you be paid for your time / taking part in this research study?

We will not pay for the time you take to be in this study. However, at the end of the study, should you choose to provide your e-mail address (separately from the survey), you will be entered in a prize draw for one of two $50 visa gift cards.

Who can you contact if you have questions about the study?

If you have any questions or concerns about what we are asking of you, please contact the study leader or one of the study staff. The names and telephone numbers are listed at the top of the first page of this form. Or you can reach us at

Who can you contact if you have complaints or concerns about the study?

If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail or call toll free 1-877-822-8598.

Can you choose to provide consent, or withdraw from the study?

Taking part in this study is entirely up to you. You have the right to refuse to participate in this study. If you decide to take part, you may choose to pull out of the study at any time without giving a reason and without any negative impact.

How do you provide your consent to be included in this study?

Proceed to the video, then complete the questionnaire on the following page. If the questionnaire is completed and submitted, it will be assumed that your consent has been given. Your signature is not required.

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