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Example: last 4 digits of ID card number (X-XXXX-XXXX1-23-4)
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Participant Information Sheet

This document may contain the wordings that you might not understand, please ask the principal investigator or representative to explain until understanding. You may take the document to read at home to consult or discuss with relatives or close friends, your physician or other physicians to help making decision in participation.

Project title Development of health care System and community health through a healthcare database (Bangkoknoi model 2)

Name of Principle Investigator Assoc.Prof.Dr.Naris Kitnarong

Research site Bangkoknoi district

Affiliation and Telephone number of principle investigator which can be reached in and after office hours Tel.02-419- 9065 and 090-990- 6184

Source of funding Thai Health Promotion Foundation
No Conflict of interest declare
Duration of research Research period 1 October 2016 – 30 September 2018

Background/rational

The Bangkoknoi model is the healthcare model for urban communities. It was established by the Faculty of Medicine Siriraj Hospital. This project is collaborating with Thai Health Promotion Foundation and various agencies to create a health database with many factors that affect the health and wellbeing of people who live in Bangkoknoi district, Bangkok, Thailand. This model will help healthcare providers and citizens to prevent some diseases or illnesses and promote health. This project meets the needs of Thai health policy and supports the Thai situation which will become an aging society in the near future.

The project is divided into three phases. The first phase is studying information and developing questionnaires including developing a database for information of health in the Bangkoknoi community and creating a network and learning data management system for healthcare. Second phase is the planning and implementing process to collect the data by planning with each local community’s leaders in Bangkoknoi district (Bangkoknoi district has 42 Communities) and Party network in the area. Third phase design data normalization performed and finding solutions for health promotion in Bangkoknoi district in pilot project by sending data to Department in Faculty of Medicine Siriraj Hospital and Government organizations in the area to analyze and create projects or activities to solve the reason of health problems.

The benefit of this project will help patients to understand their health that leads to adjusting and modifying behavior and environment to support good health and prevent illness which will become an aging society. In addition, we will know the incidence of infectious disease that requires intermediate intervention. The aim of this model is to improve Thai population health and to be the prototype for the healthcare model for taking care of the local communities by local organization to other districts in Thailand, especially in urban communities. So, The Faculty of Medicine Siriraj Hospital is not only the medical school but we are “beyond a medical school”.

Objectives

1. To create a community health database in the Bangkoknoi district area by collecting health data and other factors affecting health care.

2. To study health problems and factors affecting health care in urban communities using Bangkoknoi community as a case study.

3. To test the effectiveness of health data collection tools, including the Bangkok Noi model application and applications used on the website.

You are invited to take part in the research because You are the target group, aged 18 years and over, who have an impact on health and other factors of the Bangkoknoi community.

There were approximately 177,710 participants/volunteers in this study.

1. Data were collected for all age groups of 42 communities in Bangkoknoi area. The main target group is elderly group People in Bangkoknoi area 158,533 people (Source: 2010 Population and Housing Census)

2. Personnel of Faculty of Medicine Siriraj Hospital, 15,715 persons (Source: Personnel data of Faculty of Medicine Siriraj Hospital for the year 2015)

3. 3,462 students under the Faculty of Medicine Siriraj Hospital (Source: Student data, Faculty of Medicine Siriraj Hospital, 2015)

If you have decided to participate in the research there will be research steps as follows:

Ask those involved or the research team bring the documents that will be participating in the research project for you to read and know about it, along with signing consent to participate by asking you to answer the questionnaire according to attached document so that the research team can collect useful information and can be used information in the questionnaire.

The risk that may occur when taking part in the research

You will not be exposed to any risks or discomfort when answering the questionnaire, but there may be questions that affect your discomfort such as uneasy to provide information.

If you have any inquiries regarding the research or if the unwanted side effect from the research occurs, you can contact

Assoc.Prof.Dr.Naris Kitnarong Tel.02-419- 9065 and 090-990- 6184

The benefits that are expected to be derived from research

Your information will be a database of hospitals that can be used to plan treatment in the future.

(There is no compensation that co-researchers/volunteers will receive.)
(There are no costs that the co-researcher/volunteer will be responsible for themselves.)

If there are additional information both advantage and disadvantage involve in the research, the researcher will inform the participant immediately.
The personal data of the participant/volunteer will be kept confidentially and will not disclose to public individually. The report of research result is provided as whole information. It may be posted on http://www.ClinicalTrials.gov or http://www.ClinicalTrials.in.th. However, the individual subject’s data may be able to disclose for a body of person to investigator such as sponsor, auditing division of the government organization and Institutional Review Board Committee.
The subjects have a right to withdraw from the project at any time without giving advance notice or reason. Furthermore, the withdrawal of project will not affect the received treatment and services.
If you are not treated as stated in this participant information sheet, you can make a complaint to the SIRB chairman, Office of Siriraj Institutional Review Board, Room 210, 2nd floor of His majesty the King’s 80th Birthday Anniversary 5th December 2007 Building, Telephone 66 2419 2667-72, Fax 66 2411 0162