General Health Questionnaire - Report Example

Questionnaire and consent form for research on diabetes General Health Questionnaire We want to know how your health has been in general over that last few weeks. Please read the questions below and the given options. Please check () the response that best applies to you. Thanks you for answering all the questions. 1. Have you been advised diet control by the doctor in the recent months (3-4 months)? Yes No 2. Do you feel extremely tired after continuously working for 1-2 hours? Yes No 3. Do you feel the urge for frequent urination, which in turn makes you thirsty during working? Yes No (Note: The excess glucose in the body of a type-2 sugar affected person would draw more water from his tissues, hence the need for more urination. This in turn results in dehydration and causes thirst) 4. How will you assess the weight of your body in the last three months a. It is the same b. It has increased a bit c. It is going down substantially 5. Do you feel any difference in your vision in the recent months? a. I can see perfectly all right b. I experience blurred vision 6. Do you feel that infections or minor injuries in your body take more time in healing? Yes No 7. Do you feel any kind of depression? a. At times, when I am alone b. Frequently, with excessive workload in recent months c. Generally not 8. Anybody in your family suffering from Diabetes a. No b. Grandparents c. Parents d. Siblings or cousins 9. Do you have a fixed schedule of work-outs/ Going to Gym? a. No b. No, But I undertake regular walks c. Yes, I am a regular at Gym 10. What type of precautions do you take in your diet? a. I have no reservations b. I try to avoid food with sugar content c. I strictly go by Doctors’ advise Consent Form to be signed by the Research Participant I confirm that this study is being undertaken to analyse the impact of Diabetes among the Lebanese Community in Sydney I confirm that I have read and understood the information sheet/letter of invitation for this study. I have been informed by Mr/Ms……………………….about the purpose, risks, and benefits of taking part. I understand what my involvement will entail and my queries about the study have been answered to my satisfaction. I understand that my participation is entirely voluntary, and that I can withdraw at any time without prejudice. I understand that all information obtained will be confidential. I agree that research data gathered for the study may be published in academic journals/ newsletters provided that I cannot be identified as a subject. Contact information of the researcher has been provided to me and in case I wish to seek further information from the researcher I can do so on these contact numbers/ addresses. Participant’s Signature------------------------------------------------- Date --------------------------------------------------------------------- Place --------------------------------------------------------------------- Signed Statement by the Researcher (On the same sheet as the consent form) I have explained this project and the implications of participation to this participant without bias and I believe that the consent is informed and that he/she understands the implications of participation. Name of the researcher ------------------------------------------------------- University ----------------------------------------------------------------------- Course --------------------------------------------------------------------------- Signature of the researcher --------------------------------------------------- Date ------------------------------------------------------------------------------- Place ------------------------------------------------------------------------------ Contact Telephone No/s ------------------------------------------------------- E-mail id ------------------------------------------------------------------------- In case, if at any stage the researcher is found to indulge in unethical behaviour or any research participant wishes to lodge complaint about the researcher, the contact details are as below: The Ethics Complaints Officer Southern Cross University PO Box 157 Lismore NSW 2480 Email: ethics.lismore@scu.edu.au (NOTE: All information is confidential and will be handled as soon as possible.) INFORMATION SHEET Remember, use language that is easily understood, check spelling and grammar. Name of project – Impact of Diabetes among the Lebanese Community in Sydney Brief Introduction – This is to be written by you Name: Course of study: Name of University/ College: Basic Purpose of the study: Purely Academic What is this research? This research is being undertaken to assess the prevalence of Diabetes amongst the Lebanese community is Sydney. An effort has also been made to see to what extent the modern day life style has contributed towards this. What does this research involve? This research involves studying some of the research papers on the subject This research involves the completion of a simple questionnaire. This research involves interviews. My responsibilities to my participants I will not put any participant in difficulty by naming him/her in the study without his/her consent. If the participant agrees to take part in the study, I will be approaching him in a manner most convenient to the participant through email, phone, fax or in person. This study being for academic purposes, does not include any payment to the research participants. Your participants’ responsibilities for this research Participation in the study will certainly not take much of your time. The questionnaire is simple and it is expected that the participants will respond in a truthful manner. The questionnaire includes simple questions about their routine living style, food habits etc. I shall be grateful to the participants if they can respond to all the questions in the questionnaire, as that will enrich my knowledge base. However, it is all voluntary. If at any stage, the participant feels like not responding he/she is free to do so. The likelihood and form of dissemination of the research results, including publication Results of the study may be published in university journal or similar such scholarly journals. The results might also be discussed during the conferences being held under the aegis of our University, but it would be made sure that no names are identified and only group data are presented. Participant’s Consent – Is consent to this research implicit or explicit? Participants are required to sign the consent form while answering the questionnaire. Therefore consent for the study needs to be explicitly stated for the study. The consent form is being attached with the questionnaire. Inquiries For any inquiry the researcher can be contacted through the telephone numbers and email id provided in the researcher information form attached along with the questionnaire. Feedback Study results would be published in college publication, and if any participant wishes to have more details about the study at a later stage, he/she can ask for the same from the researcher. Has this research been approved by the University? This research has been approved by the Human Research Ethics Committee at Southern Cross University. The approval number is ECN-??-??? Complaints about the research/researchers This info has been included in the consent form/ questionnaire. SECTION 7: PARTICIPANT INFORMATION AND CONSENT (refer to the National Statement on Ethical Conduct in Research Involving Humans, p.12-13, p.28-29, p. 40-42, p.44-45, p.47-50, p.54) This section is obligatory 7.1 Will a Participant Information Statement be provided?  Y N The proforma for the Participant Information Sheet and Consent Form should be followed closely. If Participant Sheets and Consent Forms exceed three pages in total, they will not be read carefully by most potential participants. For this reason, any Information Sheet and Consent Form exceeding this length will not generally be acceptable. Major inclusion and exclusion criteria for participants should be mentioned in any Information Sheet or Consent Form. Risks of participation should be outlined clearly, in lay language. An Information Sheet or Consent Form which asserts that there is no risk to the participant is rarely acceptable. (Doesn’t this apply to any consent? Does this add anything?) If the participant has any relevant form of disability (e.g. mental illness), consent should be obtained from the participants next-of-kin, trustee or other legally appropriate person. A Parental Information Sheet and Consent Form may be adapted for this purpose. Applicants and Guardians should consult the relevant legislation to ensure that the person giving consent has the power to do so. It is unacceptable to request a written release from a legal claim by the participant. If a Consent Form or Participant Information Sheet is amended, it should be marked (e.g. Amendment 1, with the date of the amendment). Go to link NS 2.2 (General requirements for consent) and www.usyd.edu.au/ethics/human under “Sample Documents” 7.2 Will written consent be obtained?  Y N Written consent is not usually required for questionnaires. The return of the questionnaire to the Investigators may be taken as evidence of consent to participate, however, the participant should be given a Participant Information Sheet for such research. The requirement for written consent might be waived under certain circumstances – go to link NS 2.2.5 and www.usyd.edu.au/ethics/human under “Sample Documents” If you answered NO to either 7.1 or 7.2, give reasons why not. 7.3 In the case of participants who may not be fluent in English or who have  difficulty understanding English, will arrangements be made to ensure comprehension of the Participant Information Statement and Consent Form? Y N If the project involves an invasive procedure, extensive questioning or investigation of a participant, then the participant should be provided with an Information Sheet and Consent Form in his/her own language. An interpreter should be used to ensure that the participant is fully informed except where the Investigator speaks the same language as the potential participant and undertakes to inform the participant. Go to link NS 5.2.16 (Participants’ interests) If you answered NO, give reasons. If you answered YES, what arrangements have been made? I will take along someone who is fluent with their dialect and can translate the content in their local language. Getting the content translated into multiple languages is certainly not possible for this study. 7.4 (a) Do the Participant Information Statement and Consent Form have:- – the first page of the Participant Information Statement and  Consent Form printed on appropriate institutional letterhead? Y N – the title of the project on every page, including the Revocation of  Consent? (if one is required) (Use a short title as appropriate) Y N – the page numbers expressed as page 1 of .., 2 of .., 3 of .. etc?  Y N – an assurance that participation is voluntary and participants  are permitted to withdraw from the project at any time without penalty? Y N Go to link NS 2.2.19, 2.2.20 (Withdrawing consent) – the name and telephone number of an appropriate researcher?  to respond to queries about the research protocol Y N – a telephone number, fax number and E-mail address for  the HREC, should a participant wish to make a complaint about Y N the conduct of the research project? Go to links NS 5.6 (Handling complaints) and 4.8.16 (Local complaints mechanisms) (b) How has the possibility of withdrawal from the study been addressed in the Participant Information Statement and Consent Form? It has been clearly stated that ‘the participation in the study is entirely voluntary and anybody desirous of withdrawing his/her consent can do so at any stage of the study.’ Note that the above issues will be addressed by adhering closely to the proforma for the Participant Information Statement and Consent Form available from the website (www.usyd.edu.au/ethics/human under “Sample Documents”). Proceed to Section 8. Read More