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Last Updated 10/7/05
Anonymous Survey on Pre-Use Check of Anesthesia Machines

Informed Consent for Anonymous Survey on the Anesthesia Machine Pre-Use Check
University of Florida IRB Protocol #2005-U-461

I am Samsun (Sem) Lampotang, Ph.D., a Professor of Anesthesiology at the University of Florida (UF). The anonymous survey that I am asking you to complete involves research on compliance with the 1993 Food and Drug Administration recommendations to perform a pre-use check of the anesthesia machine before every case. The survey questions are designed to obtain insight about the reasons for non-compliance and to seek patterns for non-compliance that could potentially be used to re-design the pre-use check to enhance compliance and effectiveness.

You will be asked to answer a few questions about the anesthesia machine pre-use check by clicking on radio buttons and check boxes as well as elaborating on your answers, if you wish, via text boxes. The Web-based survey will take about 3 – 4 minutes to complete. You can fill the survey online from any computer connected to the Internet. Your participation in this study is completely voluntary. There is no penalty for not participating. You do not have to fill or complete the survey if you do not wish to participate or if you change your mind, e.g., if you do not want to answer a specific question(s). You have the right to withdraw consent at any time without consequence. Your answers will be stored in a database on a server at the UF Department of Anesthesiology. There are no risks in participating in this survey. There will be no compensation for participating in the survey. However, upon completion of the survey, you will be provided access to a free educational simulation of the anesthesia machine pre-use check.

Your identity will be kept confidential to the extent provided by law. We ask you not to provide any personal identifiers in your answers such as your name or phone number. We will ask you for generic demographic data that cannot be used to identify you. For data analysis and pattern extraction, the set of information that you provide will be assigned a code number. Because you will not provide any personal identifiers, the code number cannot be traced to you. The results of the study will be reported in peer-reviewed publications as aggregate data and patterns related to demographic data.

I will be happy to answer any questions or concerns that you may have in participating in the survey. Please email Sem Lampotang or you may contact the University of Florida Institutional Review Board (UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; phone 352 392 0433.)

Click here to indicate that you have read the procedure described above and voluntarily agree to participate in the survey.