Consent Form

You are invited to participate in this survey aiming at identifying factors influencing healthy eating behavior. The result from this study will guide our decision on the design of effective interventions for promoting healthier lifestyle.

Please read this form carefully, and feel free to ask the researchers any questions you might have.

Title of Study: Understanding Factors Influencing Healthy Eating Behavior

Ethics Application Number:08-69

Researcher(s): Dr. Regan Mandryk, Department of Computer Science, (966-4888), regan@cs.usask.ca

Dr Julita Vassileva, Department of Computer Science (966-2073), jiv@cs.usask.ca

Rita Orji, Department of Computer Science (880-8087), rita.orji@usask.ca

Purpose and Procedure: The goal of this survey is to identify effective methods to be used in designing intervention to promote healthy lifestyle. In particular, the study seeks to understand the predictors of eating behaviors and the degree of influence they exact on our eating behaviors. The study may contribute to the research area of Persuasive Technology for Healthy Behavior Change and User modelling, adaptation, and personalization. To achieve this, we have designed a set of questions that we need you to respond to.

Potential Benefits: Findings from the study could lead to a better understanding of the type of technological intervention most suitable for encouraging healthy eating behavior.

Potential Risks: There are no known risks in this study.

Storage of Data: The data from this survey will be stored on a password-protected computer system and will be available only for research purposes. Personal identifiable information will be destroyed upon completion of data collection. The data will be kept by the researchers for a minimum of seven years upon the completion of this study in a secure storage. The consent forms and master list will be kept separately in the Department of Computer Science general office and will be destroyed appropriately when no longer needed.

Confidentiality: Once you sign the consent form, we will not require any personal identifiable information such as name, NSID, emails, etc.

Dissemination of Results: Aggregated results derived from this study will appear in a PhD thesis and articles published in peer reviewed conferences and scientific journals. However, any information that can be linked to a specific participant will be removed or altered and any quotations from participants that are published will be so only if no linkage can reasonably be made to the participant in any way.

Right to Withdraw: Your participation in this study is voluntary, and you may withdraw from the study for any reason, at any time, without penalty of any sort. You may refuse to answer individual questions. If you withdraw from the study at any time, any data that you have contributed will be destroyed at your request.

Questions: If you have any questions concerning the survey, please feel free to ask at any point; you are also free to contact the researchers at the numbers provided above or via email (regan@cs.usask.ca, jiv@cs.usask.ca, rita.orji@usask.ca). This Survey has been approved on ethical grounds by the University of Saskatchewan Behavioural Research Ethics Board. Any questions regarding your rights as a participant may be addressed to that committee through the Ethics Office (966-2084). Out of town participants may call collect.

Follow-Up or Debriefing: If you would like to know the results of this study, you can contact the researchers

Consent to Participate:

I have read and understood the description provided; I have had an opportunity to ask questions and my questions have been answered. I consent to participate in the Survey, understanding that I may withdraw my consent any time before or during the study and within one week after the study. A copy of this Consent Form has been given to me for my records.