This form is a copy of the survey consent that is presented to you when you register to take the survey.

Survey Consent Form

Principal Investigator:
Dr. Jat Sandhu
Regional Director, Public Health Surveillance Unit
Vancouver Coastal Health Authority, Vancouver, BC


  • Dr. Kendall Ho, Director, eHealth Strategy Office; and Professor, Dept. of Emergency Medicine, Faculty of Medicine, UBC
  • Dr. Victoria Lee, Medical Health Officer, Fraser Health Authority
  • Dr. Helen Novak Lauscher, Assistant Director for Research, eHealth Strategy Office, Faculty of Medicine, UBC

You are invited to participate in the My Health, My Community survey. This project is a partnership between the Vancouver Coastal Health Authority, Fraser Health Authority and the University of British Columbia.

You are being asked to participate because you are 18 or over, and you live in the Vancouver Coastal or Fraser Health regions. Please email with any questions.

Purpose and Objectives

We want to learn more about the health and wellness of your community. This project is an important step toward understanding factors affecting health in your area and how we can improve health in your community.


If you agree to participate in this project, you will be asked to complete a registration form and then fill out the My Health, My Community survey. The entire process should take 20-30 minutes to complete.

Risks and Benefits

We do not think anything in this project could harm you. This survey may help you think about the things that affect your health. This information will also influence the planning of health and municipal services.


Your confidentiality will be respected at all times. You will not be identified in any reports. The project findings will only report summary results.

Registration information is kept on secure computers at UBC. Survey information is kept on secure computers at Vancouver Coastal Health. Survey information from people living in the Fraser Health Region will be shared with Fraser Health. Anonymized data from the survey will be kept for public health planning and monitoring.


Project results will be shared in a number of different formats with

  • the public,
  • community partners/agencies,
  • health professionals, and
  • the academic community.

The results will be used to understand the health of communities in Vancouver Coastal Health and Fraser Health.


When registering in this project, you may choose to enter a draw. If you choose to take part, you can get up to 10 entries in the draw. You will get 1 entry by registering and 9 entries by completing the survey.


If you have any questions about this project, you can contact Dr. Jat Sandhu at or 604-675-3885. If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the University of British Columbia Office of Research Ethics by e-mail at or by phone at 604-822-8598 (Toll Free: 1-877-822-8598).

Participant Consent:

Your participation in this project is entirely up to you. You are free to withdraw at any time. Your participation will not affect any health care services you receive currently or in the future.

By continuing with the registration and survey, you agree that consent has been given.

A copy of this consent will be provided to you once you complete the registration process.