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Thank you for taking part in the Canterbury Ileal Pouch study. This is one of the questionnaires that we would like you to complete; it is about the impact your ileal pouch has had on your work and education, and it should take approximately 10 minutes of your time.
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 choose the option of "decline to answer". PLEASE NOTE that there is no save and continue option, so PLEASE DO NOT SHUT DOWN THE QUESTIONNAIRE BEFORE ITS COMPLETION. Thank you very much for your time. It is very important for us to learn your opinions.
Your questionnaire responses will be strictly confidential. If you have questions at any time about the questionnaires or the study, please feel free to contact me by email at: [email protected]
Please start the questionnaire now by clicking on the Continue button below. |
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| * What is your Study ID? (This was given to you in an email or a letter; if you have lost your study ID please email Alex at [email protected]) | | |
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| * 1. What is the highest level of education you have obtained? |
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| * 2. Do you feel your level of education obtained was affected by your ileal pouch? |
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| * 3. Are you currently employed? |
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| * 4. Were you previously employed? |
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| Note: If you are not currently employed, but were previously employed, please answer the following questions in relation to your previous work. |
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| * 5. How many hours do you work in a typical work day? (If you do not wish to answer this question, enter "Decline to answer") | | |
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| * 6. What is your hourly wage? (If you do not wish to answer this question, enter "Decline to answer") | | |
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| * 7. Have you had to have time off work in the last 12 months due to your ileal pouch? |
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| * 7a. How many days have you had off work in the last 12 months due to your ileal pouch? (If you do not wish to answer this question, enter "Decline to answer") | | |
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| 7b. These days were taken off work as: |
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| * 8. Do you think having an ileal pouch has affected your position at work? (Such as pay rise, receiving bonuses) |
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| * 9. Has your ileal pouch affected your work productivity? |
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| * 10. Have you used non-prescription medication for your ileal pouch in the last 12 months? |
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| * 10a. What was the cost of your non-prescription medication for your ileal pouch over the last 12 months? (If you do not wish to answer this question, enter "Decline to answer") | | |
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| * 11. Have you used any alternative health resource for your ileal pouch in the last 12 months? (ie. acupuncture, chiropractor) |
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| * 11a. What was the cost of your alternative health resource for your ileal pouch over the last 12 months? (If you do not wish to answer this question, enter "Decline to answer") | | |
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* 12. Can you think of any other costs that have arisen due to your ileal pouch? For example: travel, carer, tutor, cleaner, additional phone or internet requirements.
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| * 12a. What was the item(s)/resource(s) that added to the cost of your ileal pouch?(If you do not wish to answer this question, enter "Decline to answer") | | |
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| * 12b. What was the total cost of each of these item(s)/resource(s) over the last 12 months? (If you do not wish to answer this question, enter "Decline to answer") | | |
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| This is an optional part of the study, where you can choose to share with us any thoughts or comments you have from your experience of living with an ileal pouch. We also welcome any feedback about the study. | | |
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