Survey on Use of Medical Equipment
(Consent Disclaimer)

Returning Visitor Log In

The reason we have asked you to complete this survey is that we want to learn more about what types of medical equipment you have found hard to use, or you think might present problems for you to use.  Later, we will make changes to some equipment, making them easier for people with disabilities to use.

If you finish part or all of this survey, it means you understand how we will use the information you give us and you agree to take part in this study. Completing part or all of this survey is voluntary, and you can stop answering questions at any time, without penalty. Your identity will not be shared with anyone, and your answers will not be linked to your name in any way. This site is password protected, so no one other than the researchers will have access to your information. Your name will not appear anywhere on the data we collect.  About 200 healthcare providers, with and without disabilities, will participate in this study.

Authorization for Use and Disclosure of Protected Health Information

Completing this survey will involve your protected health information.  You will be asked to provide information about your age, current state of health, and types of disability.  This information will be stored in a password-protected computer and will only be available to Dr. Winters and the research team.  No information will be collected that identifies you or connects you to the data you give us.

The health information you give us will help us find problems that healthcare providers have had with some medical devices.  Reports will be shared with the public that describe the types of people who took part in the survey, and the problems they have had with some medical devices.  Your information will be combined with everyone else’s data.  No information will be shared about individual people.  This information will be kept secure until December 31, 2008, when it will be destroyed.

The private health information you provide may be reviewed by officials, in order to meet federal or state rules.  Reviewers may include representatives from the Department of Health and Human Services, the Marquette University Institutional Review Board, and/or the Western University Institutional Review Board.

You have the right to withdraw your permission/authorization, in writing, at any time.  To withdraw, contact Dr. Jill Winters at the address at the bottom of this page, or by e-mail at jill.winters@marquette.edu, and let her know you are withdrawing your permission to use your protected health information.  All of the health information you have already submitted as part of the study will continue to be used, but no new information about you will be collected.

You may make a copy of these instructions for your records.  Returning this survey shows that you agree to have your personal health information shared with the research team and used as described above.

You may ask questions of the research staff at any time during the study by contacting:

Erin Schwier  
Center for Disability Issues and the Health Professions
Western University of Health Sciences

309 E. 2nd Street
Pomona, CA 91766-1854
Phone: (800) 832-0524

E-mail: info@rerc-ami.org 

If you have any difficulty accessing or completing the survey or submitting the completed survey, please contact:

     Erin Schwier
           E-mail: info@rerc-ami.org
           Telephone: (800) 832-0524