SHRUG - Consent Form

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

The Shoulder Research User Group (SHRUG) is a patient and public involvement group formed in 2017, led by Professor Rangan.

SHRUG, based at The James Cook University Hospital, ensures patients, carers and members of the public are given an opportunity to influence future research at both local and national levels.

As a SHRUG member you will be able to share your views with patients, surgeons, physiotherapists, researchers and national societies such as the British Elbow and Shoulder Society (BESS).

By submitting your details you agree to receive tailored information and opportunities to be involved within the SHRUG patient forum at South Tees Hospitals NHS Foundation Trust.

Please complete the form below

If you have any questions regarding SHRUG before submission of this online form, or wish to opt out following a submitted form: please contact: stees.shrug@nhs.net.

Full Name:

* must provide value

I am a:

* must provide value

Patient

Carer

Relative

Member of the Public

reset

Address:

* must provide value

Expand

Postcode:

* must provide value

Telephone:

Mobile:

Email Address:

* must provide value

Where did you hear about SHRUG ?

* must provide value

Can you inform us of when your shoulder problem first started?

Month:

Year:

Did your shoulder problem arise following an injury?

* must provide value

Yes

reset

Did you have surgery as part of your management?

* must provide value

Yes

reset

Was Physiotherapy part of your management?

* must provide value

Yes

reset

Have you been diagnosed with one of the following?
_{(If more than one, please choose the main diagnosis)}

* must provide value

Other:

Have you had experience of or interested in one of the following topics?
_{(If more than one, please choose the main diagnosis)}

* must provide value

Have you had experience of or interested in one of the following topics?
_{(If more than one, please choose the main diagnosis)}

* must provide value

Have you had experience of or interested in one of the following topics?
_{(If more than one, please choose the main diagnosis)}

* must provide value

I consent to be part of SHoulder Research User Group (SHRUG). I have filled in my contact details form and I understand that a member of the research team can contact me to explain the role in more detail. I can then decide whether or not to contribute to research user groups (including BESS).

* must provide value

I Agree

reset

Signature:

* must provide value

Add signature

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Participant Information:

You have selected an option that triggers this survey to end right now.