THE UNIVERSITY OF BRITISH COLUMBIA AND SIMON FRASER UNIVERSITY
ACTIVE AGING BC: CHOOSE TO MOVE
Participant Information and Consent Form
Principal Investigator:
Heather McKay, PhD
Professor, Depts. of Orthopaedics & Family Practice,
Faculty of Medicine, University of British Columbia
Director, Centre for Hip Health and Mobility
Contact:
Christa Hoy, MSc
Research Manager,
Centre for Hip Health and Mobility
University of British Columbia
604-675-2581
Co-investigators:
Heather MacLeod-Williams, MPE
Program Director, Choose to Move
Centre for Hip Health and Mobility
University of British Columbia
604-875-4111 ext.52582
Dawn Mackey, PhD
Assistant Professor,
Biomedical Physiology and Kinesiology,
Simon Fraser University
Investigator, Centre for Hip Health and Mobility
Joanie Sims-Gould, PhD, RSW
Assistant Professor
Dept. of Family Practice, Faculty of Medicine,
University of British Columbia
Investigator, Centre for Hip Health and Mobility
Maureen C. Ashe, PhD, PT
Associate Professor
Department of Family Practice,
University of British Columbia
Investigator, Centre for Hip Health and Mobility
Meghan Winters, PhD
Assistant Professor
Faculty of Health Sciences, Simon Fraser University
Investigator, Center for Hip Health and Mobility
Sponsors:
This research is supported by the Centre for Health and Mobility Society.
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Introduction
You are being invited to take part in this research study because you meet the study’s
eligibility criteria.
Your participation in this research study is entirely voluntary, so it is up to you to
decide whether or not to take part in this research study. Before you decide, it is
important for you to understand what the research study involves. This consent form will
tell you about the program, why the research study is being done, what will happen to
you during the research study, and the possible benefits, risk and discomforts.
If you wish to participate, you will be asked to sign this form. If you decide to take part in
this research study, you are still free to withdraw at any time and without giving any
reasons for your decision. You may also ask to have all your data withdrawn as well
should you choose to withdraw. If you do not wish to participate, you do not have to
provide any reasons for your decision nor will you lose the benefit of participating in the
Choose to Move program.
Please read the following information carefully before you decide.
Who is conducting this research study?
Researchers from the University of British Columbia, Simon Fraser University, and the
Centre for Hip Health and Mobility are conducting the research, sponsored by the
Centre for Health and Mobility Society. The Principal Investigator is Dr. Heather McKay
from the University of British Columbia and the Centre for Hip Health and Mobility.
What is the purpose of the research study?
The primary purpose of this research study is to better understand the implementation
of Choose to Move: a choice-based physical activity program for older adults. In our
research of Choose to Move we will study the reach of the programs, context the
programs are delivered in, capacity built and impact on program participants’ physical
activity, sitting time, mobility, active transport and social connectedness. We will
conduct the research study at baseline, 3-months (end of active phase) and 6-months
(end taper phase).
Who can participate in this research study?
You can participate in this research study if you are:
 A Choose to Move program participant, are 60 or older, and demonstrate
readiness for physical activity (by the PAR-Q+ questionnaire or a letter of
recommendation from your physician)
Who should not participate in this research study?
You should not participate in this study if you:
 Cannot read or speak English
 Are unable to provide informed consent
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What does the research study involve?
1. Baseline Assessment
At the first group meeting, your activity coach will review this document with you and
address any concerns or questions you may have. You will then be provided with the
opportunity to give your informed consent to participate in the research study.
If you agree to participate, we will gather the following general information via
questionnaire: age category, sex, weight, height, mobility, ethnicity, education level. We
will also ask you to share how you heard about Choose to Move.
We will gather information in a survey about physical activity, sitting time, active
transport, social exclusion, social interaction and loneliness. This will require
approximately 15 minutes of your time, but will be a part of the normal group meeting.
This information will be collected again at 3-month and 6-month assessments.
Studies involving humans now routinely collect information on race and ethnic origin as
well as other characteristics of individuals because these characteristics may influence
how people respond to different interventions. Providing information on your race or
ethnic origin is voluntary.
You do not have to answer any questions that you are not comfortable with.
2. 3-month Assessment
The 3-month assessment will take place during the final group meeting during the 12th
week. In addition to the repeated survey, we will gather information about your
engagement with the program in the active phase and your satisfaction with the
program.
3. 6-month Assessment
The 6-month assessment will be mailed to your home and you will return it to the Centre
for Hip Health and Mobility using a pre-paid and addressed envelope. In addition to the
repeated survey we will gather information about your engagement in the program in
the taper phase.
4. Interview or Focus Group
Below you will be asked to indicate if you are interested and willing to participate in a
telephone interview or focus group. A subset (approximately 20) of those who indicate
they are willing to be interviewed will be randomly selected and invited to participate in
telephone interviews or focus groups with a member of the research team at baseline,
3-months and 6-months. Each interview will take up to 60 minutes or focus group will
take up to 90 minutes.
We will ask for feedback about the various Choose to Move program components as
well as the facilitators and barriers to physical activity participation. The information
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gathered from these interviews will be used to better understand the design and
implementation of similar interventions and programs in the future.
What are the possible harms and side effects of participating?
The risks and discomforts associated with this research study are minimal. You do not
have to answer any questions that you are not comfortable with.
What are the benefits of participating in this research study?
No one knows whether or not you will benefit from this research study. There may or
may not be direct benefits to you from taking part in this research study. We hope that
the new knowledge we obtain from this research can be used in the future to help
promote and enable the physical activity and mobility of older adults.
What happens if I decide to withdraw my consent to participate?
Your participation in this research study is entirely voluntary. You may withdraw from
this research study at any time and no reason for withdrawal needs to be provided. If
you decide to enter the research study and to withdraw at any time in the future, there
will be no penalty or loss of benefits to which you are otherwise entitled, and your future
participation in Choose to Move will not be affected. If you choose to enter the research
study and then decide to withdraw at a later time, all data collected about you during
your enrolment in the study will be retained for analysis unless you request that it be
removed also.
You do not waive any of your legal rights by signing this consent form. If you wish to
withdraw please contact Christa Hoy at 604-675-2581.
What happens after the research study is finished?
Once your participation in the research study is complete, you may request a summary
of your results. You may also request a copy of publications that result from the study.
Collected data will be kept indefinitely as results of this study will likely influence the
design and execution of future studies.
What will the research study cost me?
There are no direct costs to participating in this research study.
Will my taking part in this research study be kept confidential?
Your confidentiality will be respected. However, research records and health or other
source records identifying you may be inspected in the presence of the Investigator or
his or her designate by representatives of the Centre for Health and Mobility Society,
and the UBC and/or SFU Research Ethics Boards for the purpose of monitoring the
research. No information or records that disclose your identity will be published without
your consent, nor will any information or records that disclose your identity be removed
or released without your consent unless required by law.
You will be assigned a unique study number as a participant in this study. This number
will not include any personal information that could identify you (e.g., it will not include
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your Personal Health Number, SIN, or your initials, etc.). Only this number will be used
on any research-related information collected about you during the course of this study,
so that your identity will be kept confidential. Information that contains your identity will
remain only with the Principal Investigator and/or designate. The list that matches your
name to the unique study number that is used on your research-related information will
not be removed or released without your consent unless required by law. The program
coordinator and activity coaches will have access to your name, phone number, and
email addresses for the purposes of contacting you to set up appointments. However,
no records which identify you by name or initials will be allowed to leave the
investigators’ offices.
Your rights to privacy are legally protected by federal and provincial laws that require
safeguards to ensure that your privacy is respected. You also have the legal right of
access to the information about you that has been provided to the sponsor and, if need
be, an opportunity to correct any errors in this information. Further details about these
laws are available on request to your study principal investigator.
Please note that there is a minor limitation to your confidentiality if you participate in a
focus group. Given that it is a group situation, members of the group will be identified to
one another, thus we cannot guarantee that confidentiality will be maintained. We will
advise all participants at the beginning of the session that everything discussed during
the focus group should not be discussed outside of the group. Although the objective is
to maintain confidentiality, it cannot be guaranteed.
The interviews or focus groups will be audio recorded; only researchers on this project
will have access to this recording. Any names will be replaced with pseudonyms in
transcripts in order to protect your anonymity.
By consenting to participate in the research study, you confirm that any information you
encounter will be kept confidential and not revealed to parties outside the group.
Although the objective is to maintain confidentiality, it cannot be guaranteed.
Data will be stored indefinitely. Electronic data will be kept in secure, passwordprotected databases on computers/servers at the Centre for Hip Health and Mobility
and hard copy data will stored in a locked filing cabinet in the secure research facilities
at the Centre for Hip Health and Mobility.
Collection of recorded media (audio, video and photography)
As a Choose to Move research study participant, you are being asked for your consent
to being photographed, videotaped and/or interviewed. In the future, resulting media
(e.g., photographs, video, sound recordings) may be featured in publications and
presentations, such as newsletters, articles (in print and online), reports, press releases,
presentations at scientific conferences, and training materials. The resulting media may
be licensed for commercial gain and without limitation, be reproduced, copied, sold,
exhibited, published or distributed. You are also being asked to waive any and all claims
that you have or may have in the future against the Centre for Hip Health and Mobility
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related to the use of the resulting media and as a result, you will not receive any
monetary payment.
The optional 60-minute interview or 90-minute focus group will be audio-recorded and
transcribed for analysis. Only evaluators for this program will have access to this
recording. Data will be securely stored at the Centre for Hip Health and Mobility. The
data will be password protected and/or stored in a locked filing cabinet.
If you wish to consent to being photographed, videotaped, and/or interviewed, and to
the future use of these media for research purposes, please check the appropriate
boxes on the Participant Consent form at the end of this document.
Who do I contact if I have questions about the research study during my
participation?
The primary investigator for this study is Dr. Heather McKay. If you have any questions
or desire further information about this research before or during participation, you can
contact our primary contact Christa Hoy at 604-675-2581.
Who do I contact if I have any questions or concerns about my rights as a
participant during the study?
If you have any concerns about your rights as a research participant and/or your
experiences while participating in this study, contact the Research Participant Complaint
Line, Office of Research Ethics at the University of British Columbia, at 604-822-8598 or
toll free at 1-877-822-8598. They can also be contacted by email at [email protected].
You may also contact Dr. Jeffrey Toward, Director, Office of Research Ethics at
[email protected] or 778-782-6393.
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Active Aging BC: Choose to Move
PARTICIPANT CONSENT TO PARTICIPATE
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I have read and understood the participant information and consent form.
I have had sufficient time to consider the information provided and to ask for
advice if necessary.
I have had the opportunity to ask questions and have had satisfactory responses
to my questions.
I understand that all of the information collected will be kept confidential and that
the result will only be used for the scientific objectives.
I understand that my participation in this research study is voluntary and that I
am completely free to refuse to participate or to withdraw from this research
study at any time.
I understand that I am not waiving any of my legal rights as a result of signing
this consent form.
I understand that there is no guarantee that this study will provide any benefits to
me.
I have read this form and I freely consent to participate in this study.
I have been told that I will receive a dated and signed copy of this form.
Future Use Consent:
We may use the data collected in this research study for further analysis in future
studies interested in enhancing the health and mobility of older adults. For example, we
may examine this data in conjunction with an individual follow-up interview.
I consent for my data to be used for future studies.
 Yes  No
Interview or Focus Group Consent:
I consent and would like to be contacted about participating in an interview or
focus group (Note: not all participants who consent to participate in the interview
or focus group will be contacted)
 Yes
 No
Consent to be contacted for Future Studies:
I would like to be contacted for future studies.
 Yes
 No
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Active Aging BC: Choose to Move
Model Release Consent:
As a Choose to Move research study participant, you are being asked for your consent
to being photographed, and/or videotaped. In the future, resulting media (e.g.,
photographs, video, sound recordings) may be featured in publications and
presentations, such as newsletters, articles (in print and online), reports, press releases,
presentations at scientific conferences, and training materials. The resulting media may
be licensed for commercial gain and without limitation, be reproduced, copied, sold,
exhibited, published or distributed. You are also being asked to waive all rights you
have in connection with the photos and any or all claims that you have or may have in
the future against the Centre for Hip Health and Mobility. As a result, you are unable to
receive any monetary payment for the photos.
1. Are you willing to be photographed, videoed, audio recorded?
 Yes
 No
2. Are you willing to transfer your rights in connection with these media (video,
photographs, audio recordings) to the Centre of Hip Health and Mobility?
 Yes
 No
Signature
______________________________________________________________________
Printed name of participant
Signature
Date
______________________________________________________________________
Person obtaining consent
Study Role
Signature
Date
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