FIP Side Effects Pictogram Survey Paper version
FIP Side Effects Pictogram Survey Paper version
FIP Side Effects Pictogram Survey Paper version
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<strong>FIP</strong> <strong>Side</strong> <strong>Effects</strong> <strong>Pictogram</strong> <strong>Survey</strong><br />
<strong>Paper</strong> <strong>version</strong><br />
Please mail completed survey to:<br />
Dr Régis Vaillancourt<br />
Director of Pharmacy<br />
Children's Hospital of Eastern Ontario<br />
401 Chemin Smyth Road<br />
Ottawa, ON K1H 8L1<br />
Canada<br />
Tel/tél: (613) 737-7600 Ext. 2231<br />
Fax/téléc: (613) 738-4206<br />
E-mail/courriel: rvaillancourt@cheo.on.ca
<strong>FIP</strong> <strong>Side</strong> <strong>Effects</strong> <strong>Pictogram</strong> <strong>Survey</strong> –<strong>Paper</strong> Version ‐ English<br />
<strong>FIP</strong> side effects pictogram survey –paper <strong>version</strong><br />
The International Pharmaceutical Federation (<strong>FIP</strong>) is a global federation of national associations of pharmacists and pharmaceutical scientists in official<br />
relations with the World Health Organization (WHO). The <strong>FIP</strong> supports a number of initiatives worldwide, including the use of pictograms for health<br />
literacy. <strong>Pictogram</strong>s can be used to communicate health information to people with language barriers or limited health literacy levels. <strong>Pictogram</strong>s for<br />
use in the dispensing of medication have been developed and validated to communicate information such as dose, route, frequency, and precautions<br />
for medications. In addition to this information, it is important to communicate potential side effects of medications to patients.<br />
Through a partnership with Algonquin College, potential pictograms for 28 side effects have been developed.<br />
In order to collect survey responses in areas of the world that do not have ready access to the internet, a paper <strong>version</strong> of the survey has been<br />
developed. The aim of this survey is to evaluate which pictogram best represents each of the different side effects. This survey should take<br />
approximately 15 minutes to complete. Please answer every question and select only one answer for each question.<br />
After you have completed the demographic section of the survey you will be presented with different options for symbols. The meaning of these<br />
pictograms is given in the black box. For each pictogram, please indicate which you believe would be best understood in your surroundings.<br />
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable<br />
answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.<br />
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and<br />
will remain confidential.<br />
There are 3 ways to submit your survey responses:<br />
1. Mail the completed survey to:<br />
2. Email or fax your responses to:<br />
Dr. Régis Vaillancourt<br />
Director of Pharmacy<br />
Children’s Hospital of Eastern Ontario<br />
401 Chemin Smyth Road<br />
Ottawa, ON, K1H 8L1 CANADA<br />
Fax: (613) 738‐4206<br />
E‐mail: rvaillancourt@cheo.on.ca<br />
3. Have a health care provider or a representative of your choice enter the responses using the online survey tool on your behalf:<br />
http://www.surveymonkey.com/s/sideeffectspictograms_english<br />
If you have questions at any time about the survey or the procedures, you may contact [Régis Vaillancourt] at [+1 (613) 737‐7600 Ext. 2231] or by email at<br />
[rvaillancourt@cheo.on.ca]<br />
Thank you very much for your time and support.
1.<br />
2.<br />
Participant Information<br />
What is the highest level of education you have completed? (Circle one)<br />
• No formal schooling<br />
• High school degree or lower<br />
• College/University completed<br />
• Post‐graduate degree (eg. Master's, Doctorate, or professional degree)<br />
• Refuse to answer<br />
• Other<br />
What is your primary language? (Circle one)<br />
• Arabic<br />
• Bengali<br />
• Chinese<br />
• English<br />
• French<br />
• German<br />
• Hindu<br />
• Indonesian<br />
• Japanese<br />
• Portugese<br />
• Russian<br />
• Spanish<br />
• Other
3.<br />
4.<br />
5.<br />
6.<br />
Participant Information<br />
Which country is your current residence?<br />
• _________________________________________<br />
In which country were you born?<br />
• _________________________________________<br />
What is your age group? (Circle One)<br />
• 11‐15 years old<br />
• 16‐20 years old<br />
• 21‐30 years old<br />
• 31‐40 years old<br />
• 41‐50 years old<br />
• 51‐60 years old<br />
• 61‐70 years old<br />
• Greater than 70 years old<br />
What is your gender? (Circle One)<br />
• Male<br />
• Female
6.<br />
Participant Information<br />
Please select which career group best represents your<br />
situation (Circle one):<br />
•Administration<br />
•Advertising, Marketing and Public<br />
Relations<br />
•Agriculture, Animals and Plants<br />
•Apprenticeships/Trades<br />
•Arts, Design, Sculpture<br />
•Business and Finance<br />
•Civil Service, Local Government,<br />
Semi-State<br />
•Construction Professionals<br />
•Computers / Information<br />
Technology<br />
•Education Teaching and Lecturing<br />
•Engineering / Technology / Industry<br />
•Health & Safety<br />
•Human Resources and Recruitment<br />
•Humanities<br />
•Hotel, Catering<br />
•Insurance and Pensions and<br />
Actuarial work<br />
•Languages<br />
•Law Enforcement and Public<br />
Protection<br />
•Legal Services, Political Services<br />
•Leisure, Entertainment, Cultural,<br />
Sport and Performing Arts<br />
•Literary<br />
•Management - General<br />
•Manufacturing and Processing<br />
•Maritime, Fishing and Aquatic<br />
Business<br />
•Media, Communications, Publishing<br />
•Medical - Caregiver<br />
•Medical - Dentist<br />
•Medical - Dentistry Student<br />
•Medical - Naturopathic/Homeopathic<br />
•Medical - Naturopathic/Homeopathic<br />
•Medical - Nursing<br />
•Medical - Nursing Student<br />
•Medical - Medical Student<br />
•Medical - Pharmacist<br />
•Medical - Pharmacy Student<br />
•Medical - Pharmacy Technician<br />
•Medical - Physician<br />
•Medical - Physiotherapist<br />
•Medical - Physiotherapy Student<br />
•Medical - Psychiatrist<br />
•Medical - Psychiatry Student<br />
•Medical - Psychologist<br />
•Medical - Psychology Student<br />
•Medical, Para Medical, Health Care -<br />
Other<br />
•Motor Industry<br />
•Music<br />
•Natural Resources and the<br />
Environment<br />
•Politics<br />
•Property Sales/Management<br />
•Religion<br />
•Sales, Retail and Buying<br />
•Scientific<br />
•Social Care and Guidance<br />
Services<br />
•Student - Elementary School<br />
•Student - High School<br />
•Student - Community College<br />
•Student - University<br />
•Student - Adult Education Program<br />
•Student - Other<br />
•Tourism<br />
•Transport, Distribution
For the following, please circle the<br />
pictogram which best<br />
Circle one<br />
each side effect.<br />
represents<br />
on each page only:
Rash<br />
A B C D<br />
E F
Fever<br />
A B C D<br />
E F G H
Fatigue<br />
A B C D<br />
E F G H
Drowsiness<br />
A B C D<br />
E F G H
Weight Gain<br />
A B C D<br />
E F G H
Weight Loss<br />
A B C D<br />
E F G H
Constipation<br />
A B C D<br />
F G H I<br />
E<br />
J<br />
x
Diarrhea<br />
A B C D<br />
F G H I<br />
E
Nausea<br />
A B C D<br />
E<br />
F G H
Vomiting<br />
A B C D<br />
E F G H
Muscle Pain<br />
A B C D<br />
E F G H
Heartburn<br />
A B C D<br />
F G H I<br />
E
Insomnia<br />
A B C D<br />
E<br />
F G H
Headache<br />
A B C D<br />
F G H<br />
I<br />
E
Tremor<br />
A B C D<br />
E F G H
A B C<br />
F G H<br />
Blurred Vision<br />
D<br />
E<br />
I J
Confusion<br />
A B C D<br />
F G H I<br />
E
Dizziness<br />
A B C D<br />
F G H I<br />
E<br />
J
Dizzy When Getting Up<br />
A B C D<br />
E F G H
Shortness Of Breath<br />
A B C D<br />
F G H I<br />
E<br />
J
Ringing In Ears<br />
A B C D<br />
E F G H
Seek Medical Advice (Developed Country)<br />
A B C D<br />
E F G
Seek Medical Advice (Developing Country)<br />
A B C D<br />
E F G H
General Pain<br />
A B C D<br />
G<br />
E F<br />
H I J K L M
Coughing<br />
A B C D<br />
G H I J<br />
E F<br />
K
Avoid Sun Exposure (Photosensitivity)<br />
A B C D<br />
E F G H
Do Not Drive<br />
A B C D
Pregnancy<br />
A B C D<br />
E F G
Please mail completed survey to:<br />
Dr Régis Vaillancourt<br />
Director of Pharmacy<br />
Children's Hospital of Eastern Ontario<br />
401 Chemin Smyth Road<br />
Ottawa, ON K1H 8L1<br />
Canada<br />
Tel/tél: (613) 737-7600 Ext. 2231<br />
Fax/téléc: (613) 738-4206<br />
E-mail/courriel: rvaillancourt@cheo.on.ca
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