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.)