1. NYU Rory Meyers College of Nursing
Nursing Research Networking Study
Consent Form for IRB-FY2019-3013

You have been invited to take part in a research study to learn more about the structure, process, and outcomes of nursing research and translation conducted by members of a U.S. regional nursing research society. This study will be conducted by Robin Klar, NURSING - College of Nursing (NURSING), Rory Meyers College of Nursing, New York University

If you agree to be in this study, you will be asked to do the following:

•             Review the study flyer

•             Read the consent form

•             Consent to participate in the study

•             Complete an on-line or paper and pencil survey

•             Push submit button for on-line survey or deposit in locked box if participating in paper and pencil survey.

Participation in this study will involve 10 minutes. There are no known risks associated with your participation in this research beyond those of everyday life..

Although you will receive no direct benefits, this research may help the investigator understand the structure, process, and outcomes of nursing research and translation conducted by members of a U.S. regional nursing research society. .

Confidentiality of your research records will be strictly maintained by The on-line survey is password protected and the researcher is the only person with the password. The paper and pencil survey, once completed, will be placed into a locked box by the participant. The locked box will remain in the custody of the researcher. Information not containing identifiers may be used in future research, shared with other researchers, or placed in a data repository without your additional consent.

Participation in this study is voluntary. You may refuse to participate or withdraw at any time without penalty. For interviews, questionnaires, or surveys, you have the right to skip or not answer any questions you prefer not to answer.

If there is anything about the study or your participation that is unclear or that you do not understand, if you have questions or wish to report a research-related problem, you may contact Robin Klar at 212-992-7013, rtk3@nyu.edu, 433 1st Avenue, New York, NY 10010.

For questions about your rights as a research participant, you may contact the University Committee on Activities Involving Human Subjects (UCAIHS), New York University, 665 Broadway, Suite 804, New York, New York, 10012, at ask.humansubjects@nyu.edu or (212) 998-4808. Please reference the study # (IRB-FY2019-3013) when contacting the IRB (UCAIHS).

You have received a copy of this consent document to keep.

Agreement to Participate

 

 

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Subject's Signature & Date

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* 1. What is your year of birth

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* 2. What is your race?

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* 3. Are you Hispanic or Latino? (Check only one)

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* 4. What is your gender identity?

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* 5. What is your highest earned degree?

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* 6. 1.       What is your current job title?

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* 7. In what type of setting do you work in your principle position? (Check only one)

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* 8. Average number of hours per week conducting research related activities:

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* 9. Years of research experience

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* 10. .  What is the approximate number of publications

        you publish annually?

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* 11. Approximately, what percentage of your research is conducted with colleagues outside your institution?

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* 12. Which of the following would best classify your primary research area?

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* 13. What percentage of your time do you spend collaborating with other nursing researchers in the following geographic regions? US Northeast

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* 14. .What percentage of your time do you spend collaborating with other nursing researchers in the following geographic regions? US South

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* 15. What percentage of your time do you spend collaborating with other nursing researchers in the following geographic regions? US Mid-West

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* 16. What percentage of your time do you spend collaborating with other nursing researchers in the following geographic regions? US West

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* 17. What percentage of your time do you spend collaborating with other nursing researchers in the following geographic regions? International

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* 18. During research collaboration, what mode of communication do you most frequently use when working with colleagues within your institution?

    (Please rate: 1- Most frequent to 7- Least often)

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* 19. During research collaboration, what mode of communication do you most frequently use when working with colleagues outside your institution?

    (Please rate: 1- Most frequent to 7- Least often)

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* 20. On average, how many STUDENT research team members contribute to your combined research program efforts?

(please indicate number)

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* 21. On average, how many ACADEMIC FACULTY research team members contribute to your combined research program efforts?

(please indicate number)

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* 22. On average, how many RESEARCH COORDINATOR research team members contribute to your combined research program efforts?

(please indicate number)

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* 23. On average, how many RESEARCH ASSISTANT research team members contribute to your combined research program efforts?

(please indicate number)

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* 24. On average, how many CLINICAL STAFF (RN/NP/MD) research team members contribute to your combined research program efforts?

(please indicate number)

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* 25. 1.       Please indicate the name of your primary research institution?

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* 26. In the past 5 years, which regional, national, and/or international institutions  have you collaborated with?  (Please indicate frequency for each category) 

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* 27. In the past 5 years, which regional, national, and/or international institutions  have you collaborated with?  (Please indicate frequency for each category)

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* 28. In the past 5 years, which regional, national, and/or international institutions  have you collaborated with?  (Please indicate frequency for each category)

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* 29. In the past 5 years, which regional, national, and/or international institutions  have you collaborated with?  (Please indicate frequency for each category)

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* 30. In the past 5 years, which regional, national, and/or international institutions  have you collaborated with?  (Please indicate frequency for each category)

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* 31. In the past 5 years, which regional, national, and/or international institutions  have you collaborated with?  (Please indicate frequency for each category)

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