"Enabling Health with Quality Online Tools"

Survey Consent Form

This is a copy of the survey consent form that is presented to you on the survey website.


Title of Project: South Asian Diabetes e-Patient Project

Dr. Mark Makowsky, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta.
Dr. Charlotte Jones, Faculty of Medicine, Southern Medical Program, University of British Columbia.
Dr. Shahnaz Davachi, Director, Diverse Populations, Alberta Health Services.

We are asking adults of South Asian background to do a survey about how they are using the internet, smartphones, and applications (Apps) in every day life and for health.  Whether or not you use these things yourself, we would be grateful for your time to answer a few questions.  This will take about 15 to 20 minutes to complete depending on your answers. 

What is the purpose of the study?
The study team wants to look at the possibility of using new communication technologies like smart phones, social media, and the internet, as tools for people to stay healthy or to help people with chronic health issues to better self-manage their conditions.  We think that these types of technology may be able to help increase knowledge, confidence, and health behaviors to prevent or treat conditions like type 2 diabetes and heart disease. 

What will happen? 
We will ask you questions like "Do you own a cellphone" and “Have you looked for health information online in the past 12 months."  By completing the survey you are implying your consent to participate. Once you complete the survey, your name will be entered into the e-Patient Project Prize draw for a chance to win an Apple iPad mini (16GB) or other gift cards ranging in value from $25 to $50.  When you give us your contact information for the Prize draw, we will also ask for your permission to contact you in the future to see if you are interested in learning more about our project.  You can still enter the draw and not have us contact you in the later phases of our project if you do not want to. The prize draw runs from approximately May 18th, 2014 to July 31st, 2014 and prize winners will be contacted by telephone and/or email. Further information about the prize draw can be found at www.epatientproject.ca.

Are there any risks and/or benefits?
There are no direct benefits to you. Your participation in this survey is voluntary, meaning you do not have to take part if you don’t want to. You do not have to answer specific questions if you do not want to. By participating you will be helping us learn about how new technology might assist people in your community to better take control of their health and wellness. There are no known risks to you by participating in the survey.

Will my confidentiality be protected?
All information collected from you will be confidential and we will not identify you by name or other identifiers, only by a coded number.  Your contact information, provided for the purposes of the prize draw will be help separately from your survey responses.  Only the research team will have access to a copy of the survey. We will keep the information stored one a secure server at the University of Alberta for a minimum of 5 years.  Results of the study will be presented at educational meetings and published in professional journals. Any report published as a result of this study will not identify you by name or other identifiers.

If I decide to start the study, can I change my mind?
You can stop the survey at any time without giving a reason. 

What if I have questions? 
If you have concerns about your rights in this study, you may contact the University of Alberta, Health Research Ethics Board at 780-492-0302. These offices have no relation with the research team. 

If you have any questions about the study, please feel free to contact:  Mark Makowsky, Assistant Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta at 780-492-1735 email: makowsky@ualberta.ca, Kaitlin Lauridsen,Project Manager at Kaitlin4@ualberta.ca or Bikram Jammu,Community Coordinator at bjammu@ualberta.ca