course helps you learn about weight loss and exercise through Continuous Quality Improvement.
You are asked to apply the principles of continuous quality improvement to improve
must meet the following eligibility requirements to participate:
You must choose for yourself what you want to do
(lose weight, exercise more, etc.).
You must be more than 18 years old.
You must be in good health.
You must be taking a course in which the principles of
Continuous Self Improvement is taught.
What are you agreeing to do?
Your instructor is
asking you to:
a habit that you want to change.
process owners that can help you with the change.
with your process owners how daily routines affect the habit.
with your process owners how to change your habit by modifying your
Implement a number of changes
Monitor your success.
Plot your success in a control chart
your data (storyboard) with process owners and the instructor.
you choose and if you remove your name and image from the storyboard, you
may share your storyboard with others in class.
an exit interview evaluating the success of the effort. No personal
identifying information are requested in the Exit interview.
In addition, keep the
following in mind:
grade does not depend on your success in bringing about the change in your
will be evaluated based on the process you used to bring about the change
and not based on the outcomes you achieved.
do not have to do this project. If
you do not wish to learn about quality improvement through a personal
project, you can select to work on other projects.
Risks you face
You may face several risks
by participating in this course:
changes in a personal habit, e.g. exercising, may put you at additional
health risks. Consult your
doctor before you deciding to engage in strenuous exercise or sudden changes
in your diet. If you feel
distressed about achieving your resolution, contact your primary clinician,
or the resources described at the following site:
Success is not guaranteed. You
may not succeed in brining about changes you want to accomplish.
You may be disappointed. Keep
in mind that habits are difficult to change.
Any relapse to old habits is a new learning opportunity.
You can investigate what caused the relapse and take steps to reduce
the frequency of relapse.
may feel uncomfortable in sharing your personal habits with others in class.
You do not need to do so. While
with other students provides additional learning opportunities, it is not required.
instructor is not a counselor or a clinician. He
is not providing you with medical or mental health advice.
If you need medical advice or mental health counseling,
seek information from your health care professional and not from your
collect information about you through the web.
No computer transmission can be perfectly secure.
We are asking you to take reasonable efforts to protect the
confidentiality of your transmissions. In
particular, we ask that you do not provide your name or identity or student
ID number in any of the survey responses.
Instead, your instructor will provide you with a code that you
can use in responding to online surveys.
post the story of your improvement on the web so that other students could
learn from your experience. To
reduce the possibility of releasing your identity to others, we ask that you
do not provide your name, image or any identifying information on any
storyboards or material you supply to the instructor.
If you do not wish to post your storyboard on the web, please indicate
your preference to your instructor by writing on the material you provide to
- YOU SHOULD
NOT USE THE COURSE OR THE INSTRUCTOR FOR AN EMERGENCY.
communications to the instructor are delayed and are not received at the time
sent. In case of an emergency,
you should go to the emergency room or call 911.
Voluntary nature of participation
Your participation is voluntary
and you may withdraw from the personal project at any time and for any reason.
There is no penalty for not participating or withdrawing.
choose to withdraw, in order to meet the requirements of the course you may
need to provide an alternative project in which system change is used to bring
about behavior change in others.
You will be asked to respond to an online survey as well
as to provide a storyboard about your improvement effort.
No personal identifying information should be on either document.
The information provided by you will be maintained on the web for at
least 3 years.
The only document that will contain your personal identity is this
informed consent. This informed
consent will not be linked to your reports of personal improvement. The
written consent will be maintained under lock at Dr. Alemiís office and will be
destroyed within a month after you complete your course.
The personal benefits for participation include:
There are no costs to you
nor will you receive
money for your participation in this project.
Except for the benefits listed above, there are no other benefits for
participating in the study.
Who is conducting the study?
Farrokh Alemi Ph.D. at George
Mason University is conducting this study.
He may be reached at 703-993 4226 for questions or complaints.
You may also contact the George Mason University Office of Sponsored
Programs at 703-993-2295 if you have any questions or comments regarding your
participation in this research.
have read this entire form, or it has been read to me, and I understand it
completely. All of my questions
regarding this form or this study have been answered to my complete
satisfaction. I agree to
participate in this study.
Signature of Investigator
the best of my knowledge the above person has assimilated the entire
content of the consent form, and understands the study and it risks as well. His or her questions have been accurately answered to his or
Investigator Name: Farrokh Alemi
Where to Send Signed Consent?
Please print and sign this consent form. Send
the signed consent by fax to 703 993 1953 or mail to Farrokh Alemi at College of
Nursing and Health Science, George Mason University, 4400 University
Drive, Fairfax, Virginia 22030-4444.
This page is part of the course on
Quality/Process Improvement the lecture on
Improvement. This document was last revised on
Ph.D. Approval for the use of this document expires on Jun 22nd
2005 protocol 3606 of George Mason University Institutional Review Board (IRB)