CONSENT FORM FOR RESEARCH PARTICIPATION

Title:

Factors affecting health decisions during the H1N1 pandemic.

Investigators and Institution:

This study is being conducted at McGill University and the Douglas Mental Health University Institute (6875 LaSalle boulevard, Montréal, Qc, Canada, H4H 1R3), by the following investigators (in alphabetical order): Andrea Ashbaugh, Ph.D.; Nelson Azoulay, M.Sc. Candidate.; Alain Brunet, Ph.D., (principal investigator); Christophe Herbert, Ph.D Candidate.; Lening Olivera, Ph.D., & Elena Saimon, B.A.

Study Sponsor:

The research laboratory of Alain Brunet, Ph.D. (Douglas Institute/McGill)

Study Purpose:

To increase our understanding as to how information, emotion and beliefs influenced people’s decisions to receive the H1N1 vaccine. We will be recruiting 1000 participants from Canada, the United States and the United Kingdom.

Criteria for Inclusion:

  • 18 years old or older
  • Internet access
  • English speaking

Criteria for Exclusion:

None.

Description of the Study:

You are being asked to answer a series of questions on your mental and physical health, your sources of information regarding H1N1 Influenza (swine flu) as well as your beliefs about the virus. After providing consent (i.e. if you click on the ‘agree’ button after reading this document), you will spend about 20 minutes filling out questionnaires in a single session. We ask that participants only complete the study one time.

Advantages and Disadvantages of Participating in the Study:

There is no known advantage or disadvantage to participating in this study. You may experience some mild temporary discomfort when completing questionnaires about your current emotional state about the H1N1 virus.

Voluntary Participation:

Your participation is voluntary. Lack of participation will not affect the quality of the medical care you receive. You can terminate your participation at any time without any consequence to you. You are also free to skip any question you prefer not to answer.

Confidentiality:

Completed surveys will be stored on a secure computer (a server) owned by McGill University (Canada). Although we will scramble (encrypt) your data while it is being transmitted from your computer to our server, there is a very small risk that confidentiality could be breached during this process.

In order to protect confidentiality, we will remove from your file any information which could identify you; your file will only be identified by a number. The list matching your personal information (your name, IP address, and e-mail) with your file number will be kept in a separate database. Access to this list will be restricted to the research personnel of the Principal Investigator. You may also choose to fill-out the survey without providing any personal information, if you wish.

Confidentiality will be maintained to the extent permitted by the law. The law requires that information which involves planned harm to yourself or others be reported to legal authorities. There is a very small possibility that the research records may be requested in the future by a Canadian court.

Compensation:

Those who submit a complete survey may optionally provide their name and e-mail address to have their name entered in a draw for one of 5 gift certificates from amazon.com ranging from $25 to $100. We will contact the winners on March 1, 2010 via e-mail. Winners will be required to confirm their identity prior to receiving their prize.

Contacts:

Please address any query to Elena Saimon, administrative assistant to the Principal Investigator, at +1 514-761-6131, extension 2375. If you have questions concerning your rights as a study participant, please call the ombudsman of the Douglas Institute at +1 514 761-6131, extension 3287.

Consent:

You may print the consent form for your records by clicking here:

By clicking on the button below, you acknowledge that you have read and understand all of the above. If you refuse to participate or if you withdraw, you will not suffer any penalty, loss of rights, or loss benefits to which you are otherwise entitled. The results of this study may be published, but your records will not be revealed unless required by law.