Survey Consent for Collection, Storage and Use of Participant Information: Brace Quality of Care Experience Survey for DDH Families

You are invited to participate in this survey because you are the parent of a child who either is currently using a Developmental Dysplasia of the Hip (DDH) orthosis (e.g. brace or harness), or has used a DDH orthosis. The results will be collected confidentially. It will take approximately 10 minutes of your time to complete the survey. This survey will be running for the foreseeable future.

You are invited to participate in this survey to be administered by Dr. Kishore Mulpuri of the Department of Orthopaedic Surgery at BC Children's Hospital.

Your personal information is subject to protections under the BC Freedom of Information and Protection of Privacy Act (FIPPA). The collection of your individually identifiable information is authorized by section 26 (e) of FIPPA. The identifiable information collected through the survey will only be used for the purposes listed on this form. To participate in this study as a survey respondent, you are being asked to provide your personal views/opinions as expressed in the survey. These views and opinions are considered personal information.

We do not intend to identify you. For open ended responses, we encourage you not to provide any information that might identify you or another individual. In reporting the results of the survey we will not include any individually identifiable responses.

Access to your information is limited to the survey administrator and the technical support team at the BC Children's Hospital (BCCH) Research Institute. The survey administrator will maintain the survey, and analyze the results. You will not be identified in any reports, presentations, or publications that describe these results. You will not be provided with survey results.

As a participant in this survey, the information you choose to provide will be stored in the Provincial Health Service Authority (PHSA) BC Children's Hospital Research Institute's Secured Network electronically indefinitely. Participation in the survey is voluntary. There will be no consequences to you if you choose not to participate. This survey is completely confidential and individual responses will not be linked back to you. This means you will not be able to withdraw your consent after you participate. You do not have to answer any question that you do not want to.

Questions about your information and this survey may be directed to the Principal Investigator: Dr. Kishore Mulpuri (

For privacy related questions as a survey participant you can contact the PHSA Research Privacy office at

I have read and understand this form. I voluntarily consent to PHSA collecting, using and disclosing the information I provide as a participant in this survey. Your consent is implied through completion of this survey.

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