Human Factors Evaluation Email List Signup

Hello!

Please fill out the following form if you would like to be notified of future opportunities to participate in human factors and usability evaluations with Healthcare Human Factors. Thank you for your interest and we look forward to having you join us in the future! For more information on who we are and the work we do, visit www.humanfactors.ca

If you would like to be removed from our email list, complete the form here.

Please contact hhfdb@humanfactors.ca with any questions.

1. Name 1. Name First Last
2. Email
3. Phone number 3. Phone number - ### - ### ####

Cellphone is preferred so we can reach you easily.
4. Year of birth (YYYY)
Must be 4 digits. Currently Entered: 0 digits.
5. What is your current occupation?

5. What is your current occupation? Anesthesia Technician Anesthesiologist Biomedical / Clinical Engineer Biomedical Equipment Technician Biomedical Technologist Certified Anesthesiologist Assistant Caregiver Certified Registered Nurse Anesthetist Dentist Endodontist Engineer General Surgeon Law Enforcement Officer Licensed Practical Nurse Medical Dosimetrist Medical Physicist Medical Radiation Technologist MRI Technician Nurse Practitioner Oral Surgeon Paramedic Perfusionist Pharmacist Pharmacy Technician Personal Support Worker Radiation Oncologist Registered Nurse Registered Practical Nurse Respiratory Therapist Retiree Other (please specify): Other (please specify):

This will help us identify studies relevant to you
6. What is your current location?

6. What is your current location? Canada United States Other (please specify) Other (please specify)
7. Which city/area are you located in?

We will use this to notify you of studies happening near your location
In order to advance racial and social equity in our practices we would like to ask some additional questions. We do this to help us identify and monitor racial and social disparities in our recruitment process. Collection of this data follows Statistics Canada and Ontario’s Anti-Racism Data Standards.

Answering this questions is not mandatory, and information provided will not influence your eligibility to participate in our studies.

You may access and correct your information at any time, even after submitting the data.

If you have any questions, or would like to access your information, please contact hhfdb@humanfactors.ca
8. Do you identify as First Nations, Métis, and/or Inuit?
If yes, select all that apply.

8. Do you identify as First Nations, Métis, and/or Inuit?
If yes, select all that apply. No Yes, First Nations Yes, Métis Yes, Inuit Yes, other: Yes, other:
9. What is your ethnic or cultural origin(s)?
Please enter any applicable.

For example: Canadian, Chinese, East Indian, English, Italian, Filipino, Scottish, Irish, Anishnaabe, Ojibway, Mi'kmaq, Cree, Haudenosaunee, Métis, Inuit, Portuguese, German, Polish, Dutch, French, Jamaican, Pakistani, Iranian, Sri Lankan, Korean, Ukrainian, Lebanese, Guyanese, Somali, Colombian, Jewish, etc.
10. In our society, people are often described by their race or racial background. For example, some people are considered “White” or “Black” or “East/Southeast Asian,” etc.

Which race category best describes you?
Please select all that apply.

10. In our society, people are often described by their race or racial background. For example, some people are considered “White” or “Black” or “East/Southeast Asian,” etc.

Which race category best describes you?
Please select all that apply. Black (African, Afro-Carribean, African-Canadian descent) East/Southeast Asian (Chinese, Korean, Japanese, Taiwanese, Filipino, Vietnamese, Cambodian, Thai, Indonesian, other East/Southeast Asian descent.) Indigenous (First Nations, Métis, Inuit descent) Latino (Latin American, Hispanic descent) Middle Eastern (Arab, Persian, West Asian descent, e.g. Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish, etc.) South Asian (South Asian descent, e.g. East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Carribean, etc.) White (European descent) Another race category: Another race category:
11. What is your religion and/or spiritual affiliation?
If yes, select all that apply.

11. What is your religion and/or spiritual affiliation?
If yes, select all that apply. Buddhist Christian Hindu Jewish Muslim Sikh Indigenous Spirituality No religion Another religion or spiritual affiliaton:
12. What is your gender identity?

12. What is your gender identity? Woman Man Prefer to self-describe: Prefer to self-describe: