[Name of Company Here]
Consent to Take Part in a Participatory Ergonomics Project
TITLE: Ergonomics of Work
Ergo-Team Members: [Ergo-Team Member Name], [Ergo-Team Member Name], [Ergo- Team Member Name]
You have been invited to take part in a participatory ergonomics project. It is up to you, whether you take part or not. Before you decide, you need to understand what the project is about, what risks it might entail and what benefits you may receive. This consent form explains the project.
The investigators of the Ergo-Team will: discuss the project with you answer any questions you may have keep confidential any personal health information be available during the project to deal with any problems that may arise
If you decide not to take part or to leave the project, this will not affect your current employment status in any way.
1. Background: Any type of work has some work-related health and safety risks. We are focusing on musculoskeletal disorders (for example tendonitis and carpal tunnel syndrome). These disorders can result from repeating the same movements many times.
2. Purpose of the project: We expect to find ways to decrease the risks of these health problems. The Ergo-team is made up of both workers and supervisors and we invite your participation. We are asking you to participate with us because you work at a task we think may be putting some people at risk.
3. Description of the project procedures and tests: With your permission, we will observe you while you work and then interview you about your job; video record you at your work and analyze the recording to understand the movements you make during the work. We will then meet with you again to discuss what 8. 7. 6. 5. 4. Questions: Liability statement: Benefits: Possible risks discomforts:and Confidentiality: Although we withinthis associated participating noThere anticipated risks are project. We estimate andthe risk be tothe job might changed reduce of disorders. stress We we learnedandmorequestions. some ask likewith have toyou how discuss would also HERE ] contact please thisproject, anyIf youconcerns have about or complaints Ergo-Team, yourmembers if wish. in private of the anyIf you have other ofthe members Ergo-Team. DOES the NOTthat receivewillnoton that involve project, to be they or recorded passed information they willbe purpose usedcollect onlyoftheinformation forthe Any project. All of members yourself, outsideErgo-Team.you, you tell with orabout those the anything us we willnotHowever, use will youron talk namethiswork,about inany and report we not committee. theand tohealth safety from management occupational and our Ergo-Team ofouryour andanalysis work recommendations the and discussions. We willreport results of us Wewhat willshareinvolvement. members you tell with other our about Ergo-Team in Others willlikely company thatsimply know your involved, byseeing the you are give legalrights. upyour youunderstand When the information about the form,project. sign you this do not Signing this formgivesus your inthisIt topart take tellsyouconsent project. us that be. . your hope
questions the total time commitment be less. total 4 to timecommitment or hours there will be benefits from the project, we cannot guarantee there will willthere there benefits the guarantee we be from project, cannot Ergo-Team have signed Confidentiality Agreements ensuring any Agreements ensuring signed Ergo-Team have Confidentiality about taking part with takingany part one youin thisproject, can about meet of the Participant’s initials [ ENTER CONTACT ENTERCONTACT [
3 Consent to Take Part in a Participatory Ergonomics Project |
Telephone number: Telephone Signature of investigator that or he she freely has volunteeredto a be of part the project. participantthat the understands fully what is involved in being project, in the potential risks, any and haveexplainedI thisproject the ofto best my I questionsability. invited and answers. gave I believe be investigator:To signed by the Signature of witness Signature of participant agree have I to video-recorded. work my agree takeI to part in thisproject. understand I that to choice it is my in the be project and that may benefit.I not understand I that am toI free withdraw the from project havereceivedI enough information project.about the havereceivedI answers satisfactory to my all of questions. havehadI the opportunity ask to discussquestions/to thisproject. havereadI the consentform. be To filled bythe out and participant:signed Members:Ergo-Team TITLE : without without having give to reason a anyat time
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Team MemberTeam Name] [ Ergo-Team Member Name]Ergo-Team
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Date Date , , [ Ergo-Team Member Name],Ergo-Team
Date Participant’s initials Please check Please check as appropriate:
Yes Yes } { Yes } { Yes } { Yes } { Yes } { Yes Yes } { Yes } { Yes } { No { No { } No { } No { } No { } No { } No { No { } No { } No { }
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3 Consent to Take Part in a Participatory Ergonomics Project |