Thank you for your participation in this well-being survey. Please read the informed consent below, which explains the study, and then complete the survey questions that follow. Thank you!

Informed consent for participation in a survey:

Clinician Well-Being Survey

Consent: By completing the survey, you agree to participate in the study as described below. If you have any questions about the study or the questionnaire, please feel free to contact Dr Caroline Gomez-Di Cesare, principal investigator.

Background and Purpose: Burnout and dissatisfaction are huge problems throughout medicine internationally. Burnout (including physical, mental or emotional exhaustion; cynicism and depersonalization; and / or doubts about your competence and the value of your work) is associated with lower patient satisfaction, poorer health care outcomes, increased errors and increased costs, not to mention the huge personal toll on clinicians and our families. As part of multi-modal efforts to combat clinician distress and burnout to improve patient care, Upstate Medical University is participating in a multi-institutional collaborative program to improve clinician well-being.

Procedure: This study involves a short annual survey. As the process may be relevant to other organizations, we may publish findings on the design and effectiveness of our interventions.

Discomforts and Risks: There are no substantive risks to participating in this study. The survey should take less than 10 minutes to complete.

Benefits: Information and feedback provided in the survey will help us continually improve Upstate Medical University as a healthy place to work, as we strive to provide the optimal care for our patients.

Confidentiality: The Research Institute’s Biostatistics and Computing Center has considerable expertise in the handling and protection of study materials. There is a slight risk of breach of confidentiality. However, several safeguards are in place to make sure that your information remains confidential. No individual responses will be released. All responses associated with your participation in the study will be subject to the very strict confidentiality standards that apply to medical records. In the event of any publication resulting from this research, no personally identifiable information will be disclosed. In order to fulfill their supervisory duties, the Institutional Review Board (the committee that oversees research) and the Office of Human Research Protections may legally need to access information about responses in this study.

Right to ask questions: You have the right to ask any question you may have about this research. If you have questions or concerns, please contact Dr. Caroline Gomez-Di Cesare at (607) 547-3371 or If you have questions regarding your rights as a research subject, you may contact the Bassett Institutional Review Board Office at (607) 547-3670.

Voluntary Participation: Participation in this research study is voluntary. Refusing to participate will in no way affect your evaluations, your privileges, your access to medical care or medical services at Upstate Medical University or other employment related benefits, or affect your ongoing employment.

Thank you in advance for your time and your input.

Caroline Gomez-Di Cesare MD PhD

Bassett Research Institute

(607) 547-3371

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