Study Questionnaire

Title of Research Study: The power of perception: Understanding the influence of surgeon attire - STUDY00022203

Investigator Team Contact Information: Jenna Van Beck, MD

For questions about research appointments, the research study, research results, or other concerns, call the study team at:

Investigator Name: Jenna Van Beck, MD
Investigator Departmental Affiliation: Otolaryngology
Phone Number: 651-402-8781
Email Address: vanb0092@umn.edu
Study Staff (if applicable):
Phone Number:
Email Address:

Supported By: This research is supported by the Minnesota Lions Hearing Foundation.

Key Information About This Research Study

The following is a short summary to help you decide whether or not to be a part of this research study. More detailed information is listed later on in this form.

What is research?

The goal of research is to learn new things in order to help people in the future. Investigators learn things by following the same plan with a number of participants, so they do not usually make changes to the plan for individual research participants. You, as an individual, may or may not be helped by volunteering for a research study.

Why am I being invited to take part in this research study?

We are asking you to take part in this research study because you are an adult attendee of the State Fair visiting the D2D research building.

What should I know about a research study?

Why is this research being done?

In this study we would like to explore the impact of what physicians wear on patient confidence, trust and healthcare satisfaction. By understanding how attire influences patient trust and satisfaction, healthcare organizations can tailor their dress code policies to optimize patient-centered care delivery.

How long will the research last?

We expect that you will be in this research study for 10 minutes.

What will I need to do to participate?

You will be asked to fill out questionnaires at this visit. The first questionnaire will ask about your demographics. The second questionnaire will show you pictures of physicians wearing different types of professional clothing and ask you to rate it on different factors (e.g. confidence). No personally identifiable information will be collected.

More detailed information about the study procedures can be found under “What happens if I say yes, I want to be in this research?”

Is there any way that being in this study could be bad for me?

There may be mild discomfort answering questions as information gathered may include remembrance of specific life circumstances that may cause temporary distress (e.g., recall of a negative experience with healthcare). There is some risk of a study data breach. We comply with the University’s security standards to secure your information and minimize risks, but there is always a possibility of a data breach.

Will being in this study help me in any way?

There are no benefits to you from your taking part in this research. We cannot promise any benefits to others from your taking part in this research. However, possible benefits to others include future improvement in healthcare delivery.

What happens if I do not want to be in this research?

There are no known alternatives, other than deciding not to participate in this research study.

Detailed Information About This Research Study

The following is more detailed information about this study in addition to the information listed above.

How many people will be studied?

We expect up to 400 people here will be in this research study.

What happens if I say “Yes”, but I change my mind later?

You can leave the research study at any time and no one will be upset by your decision. Choosing not to be in this study or to stop being in this study will not result in any penalty to you or loss of benefit to which you are entitled. This means that your choice not to be in this study will not negatively affect your right to any present or future medical care, your academic standing as a student, or your present or future employment. We may keep the data that has been collected before your withdrawal.

Will it cost me anything to participate in this research study?

There will be no cost to you for any of the study activities or procedures.

What happens to the information collected for the research?

Efforts will be made to limit the use and disclosure of your personal information, including research study records, to people who have a need to review this information. We cannot promise complete confidentiality. Organizations that may inspect and copy your information include the Institutional Review Board (IRB), the committee that provides ethical and regulatory oversight of research, and other representatives of this institution, including those that have responsibilities for monitoring or ensuring compliance. We may publish the results of this research or share the resulting data. However, we will keep your name and other identifying information confidential.

Data Collected

If identifiers are removed from your identifiable private information collected during this research, that information could be used for future research studies or distributed to another investigator for future research studies without your additional informed consent.

What will be done with my data when this study is over?

We will use and may share data for future research. Data collected in this study may be made available for others to use, including for future research studies on similar or different topics, teaching, or other purposes. This could include for profit companies. Our goal is to make more research possible. We will not ask for your consent before using or sharing them. We will remove identifiers from your data, which means that nobody who works with them for future research will know who you are. Therefore, you will not receive any results or financial benefit from future research done on your data.

Whom do I contact if I have questions, concerns or feedback about my experience?

To reach the research team: Please see the “Investigator Contact Information” section at the beginning of this form.

To reach someone outside of the research team: This research has been reviewed and approved by an IRB within the Human Research Protections Program (HRPP). To share feedback privately with the HRPP about your research experience, call the Research Participants’ Advocate Line at (612) 625-1650 (Toll Free: 1-888-224-8636) or go to z.umn.edu/participants. You are encouraged to contact the HRPP if:

Will I have a chance to provide feedback after the study is over?

The HRPP may ask you to complete a survey that asks about your experience as a research participant. You do not have to complete the survey if you do not want to. If you do choose to complete the survey, your responses will be anonymous.

If you are not asked to complete a survey, but you would like to share feedback, please contact the study team or the HRPP. See the “Investigator Contact Information” of this form for study team contact information and “Whom do I contact if I have questions, concerns or feedback about my experience?” of this form for HRPP contact information.

Can I be removed from the research?

The person in charge of the research study or the sponsor can remove you from the research study without your approval. Possible reasons for removal include you do not follow study rules or if the study is stopped.

Will I be compensated for my participation?

If you agree to take part in this research study, you will receive a University of Minnesota drawstring backpack or other comparable incentives of equal value for your time and effort.


Statement of Consent

I have read the above information. I have asked questions and have received answers. I indicate my consent to participate in the study by clicking the ‘I Agree’ below.























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