1 2 3 Thank you for your interest in an interactive roundtable to discuss and learn about joint replacement experiences. To register for the roundtable discussion, please answer a few questions (approximate registration time: 5 minutes). You must be at least 18 years old to participate. Are you age 18 or older?*YesNoAre you a United States resident?*YesNo Please note: This roundtable discussion is related to hip and knee arthroplasty (joint replacement surgery). If you have had hip or knee joint replacement surgery OR if you are considering having hip or knee joint replacement surgery, we look forward to your participation in a roundtable discussion.Please select a city to attend the roundtable discussionRoundtable Discussion Location*New YorkChicagoPlease select your preferred time option to attend the roundtable discussion in Chicago from the list below* Thursday, September 8 @ 9 a.m. to 11: a.m. Central time Thursday, September 8 @ 12 p.m. (noon) to 2 p.m. Central time Thursday, September 8 @ 6 p.m. to 8 p.m. Central time None of these times work for me, but I’d like to be included on the communications list for this project in case there are other opportunities to participate. Please select your preferred time option to attend the roundtable discussion in New York from the list below* Thursday, September 22 @ 9 a.m. to 11: a.m. Eastern time CLOSED: Thursday, Sept 22 @212 Noon Thursday, September 22 @ 6 p.m. to 8 p.m. Eastern time None of these times work for me, but I’d like to be included on the communications list for this project in case there are other opportunities to participate. CONSENT INTRODUCTION: You are being invited to share your views, opinions and experiences around your hip and/or knee joint replacement surgery and the selection and decision of the implant device used for your surgery. We will provide you with information about the purpose, procedures, possible risks and discomforts, and benefits of the project. You are free to choose whether or not you would like to participate. If you decide to participate after reading this form, please sign the form below. Your participation is voluntary which means you can choose whether or not you want to participate. YOUR PARTICIPATION: If you agree to participate, you will be asked to participate in a survey and discussion about your experience with implant device selection for hip and joint replacement surgery and the impact this has had on your life. The survey will take approximately 5 minutes and the roundtable discussion will last approximately 2 hours. PRIVACY AND CONFIDENTIALITY: We remain committed to protecting the privacy and confidentiality of your health information. The information you share through the survey and roundtables will be kept in a password protected file to which only those involved in this project will have access. The aggregated information may be used for publication purposes and/or at conference presentations. We will not use any identifying information such as your name or address. If at any point you do not want to share your views and opinions and if you do not want us to use this information, you may withdraw your permission by writing to us or contacting us via phone. RISKS: There are no known risks associated with participating in this project. However, some information being requested may be of a sensitive and personal nature. Because of the sensitive nature of the information that you may be sharing with us, you may feel upset, uncomfortable or distressed. If this should happen, you may inform the organizer and stop at any time. You may choose to withdraw from participation and discontinue at any time. BENEFITS: While there are no direct health benefits, your opinions and experiences will be invaluable to the community at large and will contribute to enhancing the role of patient involvement in our health care system. In addition, as a result of your participation in this project, you may be equipped to participate as partners in future research and/or help to conduct research. Your experiences and views may benefit other individuals who are dealing with similar issues. COMPENSATION: Participants in the in-person roundtable discussion will receive $30 for local travel and $50 honorarium ($80 total). FREEDOM TO WITHDRAW: You are free to choose whether or not to participate in this project. There will be no penalty if you choose not to participate. In the event you decide to discontinue your participation, please notify Research Associate, Shilpa Venkatachalam, at [email protected] QUESTIONS: Please feel free to share your questions or concerns with the group moderator before, during, or after the survey and/or the roundtable. You may also contact Research Associate, Shilpa Venkatachalam, at [email protected][email protected] What is learned from these discussions may help other people in the future who have similar concerns about their joint replacement surgery. We hope to work alongside with you on making the lives of individuals who have undergone or may be undergoing hip and joint replacement surgery better.I have read and understood the purpose, procedures and risks and benefits associated with this project. Any questions I had have been answered and I am willing to voluntarily participate in this project:* By checking this box and typing my name below, I am electronically signing my application. Name* First Middle Last Please enter your contact info below:Email* Phone*Location* City State This iframe contains the logic required to handle AJAX powered Gravity Forms.