ENROLLMENT TO TRIAL

Consent form and demographic questionnaire

Title of Project:

E-learning to improve Junior Doctor Paediatric Prescribing

 

Name of Researcher: Dr Morris Gordon

Version 1.2 (15/05/10)

                                                                                          

1.     I confirm that I have read and understand the information sheet dated on this website        (version 1.3) for the above study. I have had the opportunity to consider the

      Information, ask questions and have had these answered satisfactorily.

 

2.     I understand that my participation is voluntary and that I am free to withdraw at any        time, without giving any reason, without my education or legal rights being affected.

 

 

3.   I understand that data collected during the study may be looked at by any of the

       researchers. I give permission for these individuals to have access to my data                           

                                                                                                                                                 

 

4.   I agree to take part in the above study.                                                                                                                                

 

Name of Participant                                

 

 

Date (ddmmyy)  

 

Signature (initials)

 

 

A copy of this consent form will be emailed to you for your records.

 

Now, please answer the demographic questions below. This information will be used to ensure equal distribution of participant characteristics between the two study groups and will be treated as confidential.

 

Email address:

 

Retype email address:

 

Age:        

Gender:                                    

 

Undergraduate Medical School:

Year of graduation:

Special study options completed during undergraduate training:

Where you a graduate entrant to medicine? (Please delete as necessary)               

YES  NO

If YES, what did you study in your previous degree?

Foundation training Year:

FY1 FY2

Please tell us the 6 job route for your Foundation Training, in order:-

 

If you answer YES to any of the following questions, please give further details in the free text box below:-

Have you ever worked as a pharmacist or in the pharmaceutical industry?

YES  NO

Have you ever worked as a graduate level doctor before taking up your foundation training post?

YES  NO

Have you received any specific prescribing training since graduating?

Please fill in all the items on this page if you wish to enrol in the trial.