FIP Side Effects Pictogram Survey Paper version

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FIP Side Effects Pictogram Survey –Paper Version ‐ English FIP side effects pictogram survey –paper version The International Pharmaceutical Federation (FIP) is a global federation of national associations of pharmacists and pharmaceutical scientists in official relations with the World Health Organization (WHO). The FIP supports a number of initiatives worldwide, including the use of pictograms for health literacy. Pictograms can be used to communicate health information to people with language barriers or limited health literacy levels. Pictograms for use in the dispensing of medication have been developed and validated to communicate information such as dose, route, frequency, and precautions for medications. In addition to this information, it is important to communicate potential side effects of medications to patients. Through a partnership with Algonquin College, potential pictograms for 28 side effects have been developed. In order to collect survey responses in areas of the world that do not have ready access to the internet, a paper version of the survey has been developed. The aim of this survey is to evaluate which pictogram best represents each of the different side effects. This survey should take approximately 15 minutes to complete. Please answer every question and select only one answer for each question. After you have completed the demographic section of the survey you will be presented with different options for symbols. The meaning of these pictograms is given in the black box. For each pictogram, please indicate which you believe would be best understood in your surroundings. Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions. 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 will remain confidential. There are 3 ways to submit your survey responses: 1. Mail the completed survey to: 2. Email or fax your responses to: Dr. Régis Vaillancourt Director of Pharmacy Children’s Hospital of Eastern Ontario 401 Chemin Smyth Road Ottawa, ON, K1H 8L1 CANADA Fax: (613) 738‐4206 E‐mail: rvaillancourt@cheo.on.ca 3. Have a health care provider or a representative of your choice enter the responses using the online survey tool on your behalf: http://www.surveymonkey.com/s/sideeffectspictograms_english 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 [rvaillancourt@cheo.on.ca] Thank you very much for your time and support.
1. 2. Participant Information What is the highest level of education you have completed? (Circle one) • No formal schooling • High school degree or lower • College/University completed • Post‐graduate degree (eg. Master's, Doctorate, or professional degree) • Refuse to answer • Other What is your primary language? (Circle one) • Arabic • Bengali • Chinese • English • French • German • Hindu • Indonesian • Japanese • Portugese • Russian • Spanish • Other
Page 1: FIP Side Effects Pictogram Survey P
Page 5 and 6: 6. Participant Information Please s
Page 7 and 8: Rash A B C D E F
Page 9 and 10: Fatigue A B C D E F G H
Page 11 and 12: Weight Gain A B C D E F G H
Page 13 and 14: Constipation A B C D F G H I E J x
Page 15 and 16: Nausea A B C D E F G H
Page 17 and 18: Muscle Pain A B C D E F G H
Page 19 and 20: Insomnia A B C D E F G H
Page 21 and 22: Tremor A B C D E F G H
Page 23 and 24: Confusion A B C D F G H I E
Page 25 and 26: Dizzy When Getting Up A B C D E F G
Page 27 and 28: Ringing In Ears A B C D E F G H
Page 29 and 30: Seek Medical Advice (Developing Cou
Page 31 and 32: Coughing A B C D G H I J E F K
Page 33 and 34: Do Not Drive A B C D
Page 35: Please mail completed survey to: Dr

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