University of Minnesota Duluth
1318 Kirby Dr
Duluth, MN 55812
St. Luke’s, 915 East First Street, Duluth, MN 55805
University of Minnesota Medical Center, Fairview-Riverside Campus, 220 Riverside Avenue, Minneapolis , MN 55454
CONSENT FORM
INSTITUTIONAL AND CONSUMER DECISION-MAKING IN THE HOSPITAL SETTING: AN EVALUATION OF A HEALTHY FOOD PRACTICES MODEL
You are invited to participate in a research study of food selection at work. You were selected as a possible participant because you are an employee at St. Luke’s Hospital. We ask that you read this form and ask any questions you may have before agreeing to be in the study.
This study is being conducted by Jennifer Schultz PhD, Labovitz School of Business and Economics at the University of Minnesota Duluth, Lara LaCaille, Jill Klingner, Rick LaCaille, Mark Branovan, Jamie Harvie, Maude Dornfeld, and Kim Nichols Dauner . It is funded by Healthy Food, Healthy Lives (HFHL) Institute Food Policy Grant Program, UMN.
The purpose of the study is to gather employee impressions of the food services at St. Luke’s Hospital and to examine the relationship between an employee’s personal characteristics and their food selection at work.
There are two parts to this study and you can choose to participate in just the first part or both parts. If you agree to participate in the first part of this study, we would ask you to complete a survey containing questions about you, including demographics, general health, eating practices, and satisfaction with St. Luke’s food offerings. The survey will take approximately 15-20 minutes to complete.
If you agree to participate in the second part of the study, you will simply be agreeing to allow access to the researchers to connect your survey responses to the food purchases you have made with your employee ID card in the cafeteria from 1/1/09 to 12/31/11.
The study has the following risks: You may potentially be uncomfortable with some of the survey questions. You need not answer any questions that make you uncomfortable.
The benefits to study participation are: There is no benefit to you other than the possibility that there may be changes to the food offerings at St. Luke’s Hospital as a result of employees’ responses.
You do not need to participate in this research. Your relationship with your employer or the University of Minnesota Duluth will not be affected in any way.
There are no costs to you for participating in this study. You will receive $10 in cash for the completion of the survey and another $10 in cash if you allow access to your food purchase records. In order to receive this money you will need to drop off your survey (if you completed the paper survey) or printed receipt of completion (if you completed the survey online) to the UMD research assistant who will be stationed in the cafeteria during the days and times provided.
In the event that this research activity results in an injury, treatment will be available, including first aid, emergency treatment, and follow-up care as needed. Care for such injuries will be billed in the ordinary manner to you or your insurance company. If you think that you have suffered a research related injury, let the study personnel know right away. You may also contact your Employee Assistance Program at 218-249-7077.
Although you will need to provide your ID number in order to receive compensation, no one at St. Luke’s Hospital except the research team statistician and UMD research staff will ever see your individual responses or be able to link your ID number to your responses on the survey. Your employer will never see your survey or your responses. Your survey information will not become part of your medical or human resources record. The primary researchers involved in the study will not see any names, and are only interested in overall group responses. Additionally, the records of this study will be kept private.
Research records will be stored securely and only researchers will have access to the records. In any sort of report we might publish, we will not include any information that will make it possible to identify you as a subject. Your record for the study may, however, be reviewed by departments at the University with appropriate regulatory oversight. To these extents, confidentiality is not absolute.
Participation in this study is voluntary. Your decision whether or not to participate in this study will not affect your current or future relations with the University or St Luke’s Hospital . If you decide to participate, you are free to withdraw at any time without affecting those relationships.
The researchers conducting this study are Jennifer Schultz, Lara LaCaille, Jill Klingner, Rick LaCaille, Mark Branovan, Jamie Harvie, Maude Dornfeld, and Kim Nichols Dauner. You may ask any questions you have now, or if you have questions later, you are encouraged to contact them at 218-726-6695. If you have any questions or concerns regarding the study and would like to talk to someone other than the researcher(s), you are encouraged to contact the Fairview Research Helpline at telephone number 612-672-7692 or toll free at 866-508-6961. You may also contact this office in writing or in person at University of Minnesota Medical Center, Fairview-Riverside Campus, 2200 Riverside Avenue, Minneapolis, MN 55454. For questions about your rights as a research participant, contact, St. Luke’s Institutional Review Board (which is a group of people who reviewed the research to protect your rights) chairperson: Gary Peterson, M.D. at (218) 249-5314.
Statement of Consent
I have read the above information. I have asked questions and have received answers. I consent to participate in the first part of this study (the survey).
Signature of Subject Date
Employee ID# (needed for compensation):
Printed Name
I consent to participate in the second part of this study (allowing researchers to connect my survey responses to my food purchases made with my ID card).
Signature of Subject Date
Printed Name
UMN IRB Code Number: 0902M59522
Version Date: 05/12/2009
St. Luke’s IRB ICF approval: May 15, 2009
St. Luke’s protocol approval: April 17, 2009
Continuing Review due date: April 16, 2010