University of Pennsylvania Research Subject Consent Form

Principal Investigator:
Samir Mehta, MD, Chief of Division of Orthopaedic Trauma and Fracture Care

Emergency Contact:
Penn Orthopaedics
3737 Market St.
Philadelphia, PA 19104
Office: 215-294-9146


You are being invited to participate in a research study.

The purpose of this study is to determine if orthopaedic subspecialty choice affects the prevalence of depression and/or suicidal ideation among practicing orthopaedic surgeons. No identifiable information will be collected and all responses will be anonymous.

Your participation in this research study is voluntary.  If you decide to participate, you are free to leave the study at any time.  If you have questions about your participation in this research study or about your rights as a research subject, please reach out to the study investigator.  You may also call the Office of Regulatory Affairs at the University of Pennsylvania at (215) 898-2614 to talk about your rights as a research subject.

Your study participation will last the length of the survey, approximately 5-10 minutes. At that point your participation and cooperation will no longer be required. No further follow-up or questioning will be necessary.

This survey is on a sensitive topic, and we are aware of the difficulties that may arise during the questionnaire. If this study is difficult for you to complete, please seek the appropriate medical and psychosocial care. The number for the National Suicide Prevention Lifeline is 1-800-273-8255.

Before beginning the survey, you will be asked to acknowledge that:
·       You have reviewed the information above about the study
·       You understand that participation in the study is voluntary
·       You agree to participate in the study

Question Title

* 1. Do you agree to participate in this study?