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Queens University

2020 Canadian Carbapenemase-producing enterobacteriaceae (CPE) Screening Survey for Hospitals and Long-term Care Facilities

HSREB Consent Form

Study Title:  Carbapenemase-producing enterobacteriaceae (CPE) Screening Practices at Canadian Hospitals and Long-term Care Facilities

Name of Principal Investigator: Filip Pajtondziev, Master of Science in Healthcare Quality, Queen’s University

Name of Supervisor: Dr. Rylan Egan, Assistant Professor of Health Quality Programs, Queen’s University

You have been invited to participate in the Carbapenemase-producing enterobacteriaceae (CPE) Screening Practices at Canadian Hospitals and Long-term Care Facilities research study. The purpose of this study is to understand how CPE screening is being performed across Canada, what screening barriers facilities might be experiencing, and what risk factors are used to determine the need for testing of inpatients and outpatients in acute and long- term care facilities.  If you agree to take part, you will be asked to complete an on-line survey. The survey should take you about 25 minutes to complete. We will ask you to provide the institution type, and the province or territory where the facility is located. Otherwise, no identifiable information will be requested. There are no direct benefits to you as a participant. There are no known risks associated with participating in the study.  Study results will help add to the body of literature about CPE screening practices, screening barriers and what risk factors are used to determine the need for testing in Canadian acute and long-term care facilities. The results of this study will be published in academic journals and presented at conferences. No remuneration will be provided for taking part in this study.

Participation is voluntary. You don’t have to answer any questions you don’t want to. You can stop participating at any time without penalty/impact on your facility. Your data cannot be withdrawn, as this survey is anonymous.

In addition to the Principal Investigator and study team, a Webmaster, who has signed a Confidentiality Agreement, will have access to the data. The survey is blinded and IP addresses will not be collected. The researcher, supervisor or Webmaster will not know who completed the survey or to which organization that member may belong. The data will be stored in a secure file in the IPAC Canada head office. Your confidentiality will be protected to the extent permitted by applicable laws. Your data will be destroyed five years after study closure. The Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (HSREB) may require access to your study-related records to monitor the ethical conduct of the research.

For ethics concerns please contact the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (HSREB) at 1-844-535-2988 (Toll free in North America) or hsreb@queensu.ca. If non-English speaking participants wish to contact the Chair for ethics concerns, translation assistance may be necessary, as the REB Chairs communicate in English only.

If you have any questions about the research, please contact Filip Pajtondziev at 18FP2@queensu.ca or my supervisor Rylan Egan at eganr@queensu.ca.

This Letter of Information provides you with the details to help you make an informed choice. All your questions should be answered to your satisfaction before you decide whether or not to participate in this research study. You have not waived any legal rights by consenting to participate in this study. This study has been reviewed for ethical compliance by the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board.

By clicking below, I am verifying that: I have read the Letter of Information and I consent to participate in this research study:

Consent