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  Back to Surveys Extracurricular Activities Questionnaire

Introduction

IDYA member Joshua Skiseng is working on a diabetes research project for Intel. You can help him by completing the survey below. Parents are asked to review the parent information notes below, and students are asked to review the student information notes. After reading these notes, interested students will be able to participate in the study through a link to the survey page.

Note: This survey is now closed.


Information on Research Study: Parent

The Effect of Extracurricular Activities on Treatment Compliance in Type 1 Diabetic Children

Principle Investigator: Thomas A. Wilson, MD (Faculty)
Co-Investigators: Andrew Lane, MD (Faculty)
Joshua Skiseng (Student)

You are being asked to allow your child be a volunteer in a research study.

Purpose: The purpose of this study is to determine whether a correlation exists between diabetic treatment compliance and extracurricular activities in adolescents.

If you decide to agree to have your child participate in this research, he/she will be asked to complete a questionnaire regarding his/or extracurricular school activities and diabetes care and control. By completing the attached questionnaire, you and your child are providing consent to participate.

Procedures: Your child will be asked to complete a questionnaire of about 26 questions regarding extracurricular activities and diabetes management. This should take about 15-20 minutes to complete. Once the questionnaire is complete, please email it to Thomas.A.Wilson@SUNYSB.EDU or mail it to the address below.

Risks/Discomforts: The following risks/discomforts may occur as a result of your child's participation in this study: You may not be happy about your child's diabetic management and discussing these issues may be upsetting to you and/or your child.

Benefits: The following benefits to you or your child are possible as a result of participating in this study: Results of this study may contribute to the knowledge of what factors may be involved in treatment compliance for diabetes. It may also serve to open discussion between you and your child about diabetes management and treatment compliance.

Payment to you or your child: Neither you nor your child will receive payment for participating in this study.

Confidentiality: Identifying information such as name, date of birth, social security number, address, telephone number, date of diagnosis is not asked and should not be provided on the questionnaire. This way, the information provided on the questionnaire is anonymous and cannot be linked to your child.

To ensure that this research activity is being conducted properly, SUNY Stony Brook's Committee on Research Involving Human Subjects, has the right to review this study and the questionnaires, but confidentiality will be maintained as allowed by law.

Costs to You: There will be no costs to you or your child for participating in this study.

Removal from Study: Your child's responses will be removed from the study if he/she does not complete the questionnaire or answers in an obviously unrealistic or frivolous manner.

Subject Rights: Your child's participation in this study is voluntary. Your child does not have to be in this study if he/she does not want to be.

You may keep this consent form.

Questions about the Study or Your Rights as a Research Subject.

If you have any questions about the study, you may contact Thomas A. Wilson, MD at telephone # (631)-444-3429.

If you have any questions about your child's rights as a research subject, you may contact Ms. Judy Matuk, Committee on Research Involving Human Subjects, (631) 632-9036.

Thomas A. Wilson, MD
Dvision of Pediatric Endocrinology
Department of Pediatrics
SUNY
Stony Brook, NY
11794-8111

Revised: August 27, 2003


Information on Research Study: Student

The Effect of Extracurricular Activities on Treatment Compliance in Type 1 Diabetic Children

Principle Investigator: Thomas A. Wilson, MD (Faculty)
Co-Investigators: Andrew Lane, MD (Faculty)
Joshua Skiseng (Student)

You are being asked to be a volunteer in a research study.

Purpose: The purpose of this study is to determine whether a correlation exists between diabetic treatment compliance and extracurricular activities in adolescents.

If you decide to agree to participate in this research, you are asked to complete a questionnaire regarding your extracurricular school activities and diabetes care and control. By completing the attached questionnaire, you agree to participate in the study.

Procedures: You will be asked to complete a questionnaire of about 26 questions regarding extracurricular activities and diabetes management. This should take about 15-20 minutes to complete. Once the questionnaire is complete, please email your response to Thomas.A.Wilson@SUNYSB.EDU or mail it to the address below at the end of this letter.

Risks/Discomforts: The following risks/discomforts may occur as a result of your participation in this study: You may not be happy about your diabetic management and discussing these issues may be upsetting to you.

Benefits: The following benefits to you are possible as a result of participating in this study: Results of this study may contribute to the knowledge of what factors may be involved in treatment compliance for diabetes. It may also serve to open discussion between you and your parent or guardian about diabetes management and treatment compliance.

Payment to you: You will not receive payment for participating in this study.

Confidentiality: Identifying information such as name, date of birth, social security number, address, telephone number, date of diagnosis is not asked and should not be provided on the questionnaire. This way, the information provided on the questionnaire is anonymous and cannot be linked to you.

To ensure that this research activity is being conducted properly, SUNY Stony Brook's Committee on Research Involving Human Subjects, has the right to review this study and the questionnaires, but confidentiality will be maintained as allowed by law.

Costs to You: There will be no costs (other than a postage stamp if you chose to mail in your response) to you for participating in this study.

Removal from Study: Your responses will be removed from the study if you do not complete the questionnaire or answers in an obviously unrealistic or frivolous manner.

Subject Rights: Your participation in this study is voluntary. You do not have to be in this study if you do not want to be.

You may keep this consent form.

Questions about the Study or Your Rights as a Research Subject.

If you have any questions about the study, you may contact Thomas A. Wilson, MD at telephone # (631)-444-3429.

If you have any questions about your rights as a research subject, you may contact Ms. Judy Matuk, Committee on Research Involving Human Subjects, (631) 632-9036.

Thomas A. Wilson, MD
Division of Pediatric Endocrinology
Department of Pediatrics
SUNY
Stony Brook, NY
11794-8111

Revised: August 27, 2003

Note: This survey is now closed.



                 
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Last Updated: Saturday October 11, 2003 15:14:00
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