Human-factor-book-cover-rev5-300-05.png


Human  Factors  
For  


 Health  Technology  Safety:  
Evaluating  and  Improving  


the  Use  of    
Health  Technology    
In  The  Real  World  


Andrea  Cassano-­‐Piché,  Patricia  Trbovich,  Melissa  Griffin,  


Ying  Ling  Lin  and  Tony  Easty  


HumanEra @ UHN
Global Centre for eHealth Innovation


University Health Network


International Federation of Medical and Biological Engineering
Clinical Engineering Division


Cover Design: Brent Bily - Envisioneering


























!
"
#$ %& ' (


! %"
) *$'
" +
( ,

"-
( + ,
(
'
" - '
. / % " 0 "-1'./%"
+ ( (


'#$22' ( " )
3 ( , &
' ( /






4,
,
(


' 5."6
. ' (
" (


. #$27 (
." " (
( (
(
."


,( ./"
!5./"!68 !58 !6
' +
."


' ( ."
' 9 : 9:
-

'

(,



' ( 9 :
." 9:
!
(


, (
"
"






.

",
" - ' . / %
"0 "-1'./%"


; )3' !/; %&/#$2<








,( (


(,


( . ,

(



'
'
, ( 9
:



3 ( ' (
!

'
(+ '' ,
(
(


/
(
( '
(
' (


' ( ( ((
'( (

!
' ( ; = > )
,
! ? . ' (
( " - ' . / @
%" ;






(
(


," , /#$2<







;


(
" - ' . /
% " (


" (
( "
(
) , " ; , " A
! ;B /(.8C 5 6/
C / ;( "
(
(5D446,(
+


"
& /
,A
! C&E&F . ! C !+ >
% ,(!% ; -=C GC
4)H433 8; .
=G> !%>



, ( ( ; ' '


/ ;
(( (
% %


. ( (
,( ;B
CC
( 5! ;6 ,( C
4 + 9+:
5;,6 /C ( /( =&(
(D4 (D 4G44 8
"
/ ( &






( %
5!"6












!
" #$ %
2 , ,/ I
# . A" ( 822
#2 ' 22
## 22
#* !. J2#
#7 ; ). '2*
#< %,; '; 27


* . ,(2K
*2 ,/ -2K
*# , 42K
** ' "2L
*7 8M / ! #$
*< " #*


$&'
( )&%
7 #L
72 #L
7# #L
7* #L
77 #I
7< ; - *$
7K - *7
7N - *L
7L 4 7$
7I ! 872






< ' .C7*
<2 7*
<# ' 77
<* .C7K
<7 7I
<< ' .C- <*
<K ! ' .C8<*


K ,(!<7
K2 <7
K# ,(!<7
K* ,(!<7
K7 ),(!<<
K< '; ,(!<K
KK ,(!<N
KN ,(!K$
KL 4 ,(!K$
KI ! ,(!8K#


) $'*
N K<
N2 K<
N# K<
N* KN
N7 KN
N< '; KL
NK N#
NN !N*
NL 4 !N7
NI ! 8NK


L ) , NN
L2 NN
L# ) , NN
L* )) , NN
L7 )) , NL
L< ; ) , NL






LK ) , 2$$
LN ) , .2$*
LL ) , 2$K


+ #$,-
I . ' ./" !2$I
I2 2$I
I# ../"!J2$I
I* ../"!J22$
I7 ../"!J22$
I< ../"!222
IK ../"!2*K
IN 4 ../"!2*N
IL ! 82*L


2$ . ' 8 !27$
2$2 27$
2$# .8 !272
2$* .8 !272
2$7 .8 !27#
2$< '; .8 !27#
2$K .8 !27*
2$N .8 !2KL
2$L 4 .8 !2KI
2$I ! 82KI


%
22 . ' ; ' ;2N#
222 2N#
22# .;';2N*
22* ).;';2N*
227 ).;';2N7
22< '; .;';2N7
22K .;';2N7
22N .;';.2LK
22L 4 .;';2LK
22I ! 82LN






./ 00# #
$ --


2# ; 2LI
2#2 ,2I2
2## " 3 2I2
2#* - 8.;2I#
2#7 " 2I*
2#< -; 56#$L
2#K ; 56" #$I
2#N ;' ; 56#$I


2* ' '' ' #22
2*2 8 ' ' A.8 !#22
2*# ; ' .' 5../"!6##*


+&*1
+&*!
002/ # ##&*-
&!&































DISCLAIMER
'
, '




2



3#3 4 .#


! &
( (
,
/

( -
( (
'
(
( ,
,
A


!(
5'>6 ,
'>
7$41. 52146
#41, M
2$$ 4 2 5. 26
#41
2$$4 5>,%'6 + 2$4
(
,

( M








#




. #000


! M
, ( M
!
,


J ! (
M
(


!

!

!
(

5.26-




*



O


' 2$4

O
5 6
( >,%'
#41
7$41 I$4

I$ 4 7$ 41


,
! (
'

,(

'
(


!
(

.
&


!
>,%'

>,%'




%
M




7


>,%'

)


,

(
-

,(
&
(




<



" ( ' .


/ % "M 5'./%"6 " - 5 "-6

& .
(
5

6
(



' (
&
!




,(

,( (

' (

'

&


,( A



(





,




K


&



!



' (
&




N


"
#$







!"


! ( (

(
( ( (


'2III ' /M " P2Q
77$$$ IL$$$ ( )
( L !
I$$$#7$$$
P#Q ) = P*Q 3 F P7Q
! P<Q LNR2#IR2KKR
' #$2* "

#2$$$$7$$$$$ )
PKQ "


!

P2Q!




/ &
5
6 !

. M (

( , ( #




L


,

&
9 : (


'

) .-! 5.-!6
PNQ
.-!M( <2$5(6

)

& %




2#


*




I


0 #$


! (
,




;

&


, ( A


• ;


• !


• '
• ;


,

! &




C
(
(
PLQ !


(


C
&

(,




2$





, &





22


0& /) 050 +


.&
( M



( (


M
PIQ% (
(


, (
P2$Q
( (O

( (

,
(
( M


(

&
.
( M



.&& #
, ''!



!
P22Q;
& (
(




2#



P2#Q P2*27Q

P2<Q
2INL
P2KQ


.&1 3#00# 6
,


,
P22N2LQ
.
A526
5#6 5*6


78" 00


!

, (

( ( P2IQ '
( M

P#$QP#2Q


7&802# #



'


!




,

'




2*


M


718


,
(
& ,
(

(
, M (
P##Q


.&* 5 #
!



( !

A


" #



A 526 5#6
5*6 M( 576


00



P#*Q
&


9 00#






(0 # #




27


' (
(


: ;


-
(
'



.&! # 0 0
. #
'



(
+
(
&


,
(


.#/< "


!
9(:) ,
( 9(:
D S MD
( ( )
(
M D
(

,


D
& !
M ,

M




2<



D
! (
( D

( ; 0



3 M J D
(
(

( (

!
,
& ' &
(
(( (
&
( ,(


!
(
9(:


"

(



.# # # #0




2K


01




(
,
G

(


, ( (
(


.1 $ = (
'(,. PIQ=>


9
:
,

!
5 6
5 6
5 6 (
5/ 6
( (


/
(
( (
( '



, $
(


.1& =>
!


> M PIQ 5. #6
&




2N


,
; ' M ;
" ;5;";6




&?@ = A..)B


, (




,
'
( 5 6



, (




2L


, (


,%&
( &


. ;
,


.11 )
(


5
6


,
'


5 6


' (
(
! (
( ! (
( (
,

; '''


.11#
!


(
(
(


.11 $#
,


A( O




2I


, (

, (

( &

(


.
' (

&
&
(


.11&
'


!
'
P#7Q





, '

P#<Q !



.111



(
! (
(
,(




#$




! (
D


<0


C (
&


5


!


)


,


+#


!


. ( 4
%5 A11(1(14 T T T6


.11&)2 #
'



( ,

( (


.1* + C.$


( '

,
8M
/58#$$$65 .*6




#2


,

(,(
&
, (

&






1 0 + C.$


'8M5.*6
(
( '
(


& (




##


.1*
,



/
,


.1* .0
!


!
( (


.1*& > 0
!


!
(


.1*1 $
! (


,
! KA*$ KA*$


.1** ?
! !


(
! !
, (


" (
&
& ,
' - , 8 ; " 5. #K6
; '''


.1*&>
,


,(


,




#*


.1! #)




1
) (

,
( (
(


, P#KQ5.76 (
( '
(




* #)7 0.$8


,
!

.7


(




#7



( (
,
( '

& ,
O
& (
,
A


)


!
! &
(
+
,
(
.
( (
(


+


8 &
(
8

-

(


+9 9(


8( (
!
&(
(

( '
( (8( (




#<


(


.0 . D


&


(
! &
( (


0D


! &
((
, ( &

!

&
&




!
.
,

( (
!

!
9:
!
,&&
( 5- ' 6









#K



$



,


(

+
&



; '' (



, A



( )

• ' .C
• ,(!

) $

• ) ,

+ #$
• . ' ./" !5../"!6
• . ' 8 !5.8 !6



• . ' ; ' ;5.;';6



A
O
O (
O +
O




#N


(
)








!





#L


0* 5


.* ..


(
,

( ' (



,
" (
( ( (
& & '
5 *6 (

; (
( (



$
(


.*& 3 5
% $



+ ( !

" ( (


.*1 3#5


( ( ,
(

(




#I


(


(
,
$

$ + M


' (+

, ( 5 *76 5
(6 (
( ,



. M
A


• '


• ) M (


• )


• ) 5
( 6


• ' (


• - (


.** 35



9 :





*$


.*! 0 5 (


.*!
-


(

O (
( . <

( (




! 00


.*! )20 #
(



'
(




*2


!

5
(1( ( 6 (
'



( (A


• J
• J


5 6J
• ( J
• J
• 5 6


J
• (( J
• J
• ( J
• J
• ( J


.*!& .
(



(
(J (
( ,

,

,
,






*#


.*!&
%


+
C +



A


• ;
• -



• -


1 5!!


• ' + 5 6


"
(!
' (

&


.*!1


( D
(

( ;


.*!*$ 0 0
, (


, (


' (

( ( (




**


( (
O (

(

-
( ! !A !




!



(
5 6

(
5
6


.*!!3
A


• ! ( 5
6


• ! 5 6


• !'-


• !


• ! (1


• 5 !!A ! 6


• ,5 6


• !


• 8 5 6 56




*7


" O


• D 1(


• (


• )


• 5 &6


• ; +


• >


.*' 5 (


.*'
'


( ((
(

+ "
(
(

5
6!(
'
5!!6( O
( +
! .K




*<


. 0#.0


(' ) * + " # %
$ *
$ $ # ! *
$ $ ' $ *
#


, *
# , ' $* ' ' *
$ $ $# *
$ ' $ - ' $
' $
' ' ' ' ' '
# * $
$ $ $ # ! $
$ $ $ . #


$ $ ' '
$ '
$' $ $
# $ $
$ # ' $ $ /
' $ # !'
# 0 $ # 1 $
23


(4' $ 3


(5' 6 !' $ $ 2 $
' ' #
' $ 3


'. 0#0


.*'&35
! ( (


5 " 7L26
(

( !
( M
!




*K


' M (
5 6
! (
.
(


' (
D
(

%
( 5 (
6


' ( (
!
9 : !
(
( ,
' (
( '
(

+ '
(( O
( (
!


'
( !


0/ '
+ ,
+
!
'
(
% + 2$$
1




*N


( (

(( (
( 5 6 8

,




(
( !




' (

( ,
(
( ( (
(


;


+
5 6
( /
& (((
(
'

'
(
( ! (
5
M 6 M
( (
; ( M




*L


M 5!!A
! 6


.*'130
! (


( (
!
( (
(
+



D
&
'
' O



(
(
+
+


.*% 3 5 (


( . &
(
)
& ,
.
A


• 5 6
• 5 6
• 5 (6
• 5 6


' &
!
.N.




*I



!




)20/+ (


78
$






9:
;
8
$ $
* $
$
$ *
$ $ $
'
$

.
<=



)20/+ ( 5 D


/.
;
78 )>
9:


&/.
! .





7$



78



1


1/0







? - $ '



$


* $ ' @
$


*/ $

<=


%5 D =


&

(


.*- > 5
%


A


.*- )
!(


( '
" P#NQ (
+ (
(
& %
(




72



(!
( 5+ " 6

+


.*-&+E
- (


,
( (
(


)
(+




.*-15
! !



4(
5 **2*6O
,
&
5
7K26


.*F 5 +
!


2 -&3&,; ;% "C&/% -
/ ! - " G ;
*576A#$$#$N


C


# /8/%4/% C -
#$$I C UB
A111 1 12$$<T- T>2#T
T




7#


%(


* G ( 'A A.
Ericsson, N. Charness, P. Feltovich & R. Hoffman (Eds.), Cambridge Handbook on
Expertise and Expert Performance. New York: Cambridge University Press, pp. 127-
145.
A11 11JV2$22LII<2*@V
2@ V




7*


0! 9<09 .#


.! .
- $


'
$ )
+ M
'
M (

$ O (
(

,
+ (


'
+ ( ,
(
( & +
5 76 &
,
P#LQ
! (
+
.
L) ,


'

-
( (



+ + +
'

(
'




77



. (
&



.!&
'


'


-
+


.!&3#6
' M


( '


'


&

'
'



. M
A


• ! 5
6


• ' ( 5
(6


• ' + M






7<


.!&&3#6
'



!



.!&10 (
8



,

3

,
& &
+ = (

&


,( '

'
( (
'
5
! !A ! 6


!
; (
+ +
' (
(


.!&*(
' +


"
5! !A
! 6) (
= ( ( M




7K



( (


8
' (
M


! ( (
+ '
+


.!&!>



( /
+ (



!
+
5 SM ( JM6 +
9:9:5S JM6
,
( 5( S
JM S JM6
, + &
( (


% (
&


.!1 <0
!


+ !
5 6 &
+ &
P#IQ!

!
A




7N


M


.!13#6
.



;

(
( !

(


. &
+
( ;
+
+ , M


. M
A


• "


• ! (


• (
• %




.!1&3#6
!





.!110 <0(
.



U




7L


'
.
(
( (
'
( (


!
+ (
%
+
(


.!1*<0(
! +


8 ( (
( )
(
8


. (
M '
'
( + M
(
M )



-
( (




M
!
(




7I


.
) 5 <K


.!1!> <0


M
, (
,

& "(
,

(


.!* .#


+
+

+


.!*3#6


M (
"


+ + -
&



(
(


. M
A


• -
• '
• ! (





<$


• ! (
+


• &
M


.!*&3#6
(



"

& +


.!*10 .#(

U
5 6
5 6 !
.L


)20 #G


56 J


TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT




.G


J5 (
6


-
8
%
%


-0 20 # #E


!

( ,




<2


(
(


' &
'
+ +
M


(
( ,
M ( M
M
( !
(
M
!
( &
( ( '

(
, (
(
+ + +


%

,

' +
(


.!**.#(



'

&&
!




<#



+ (


.!*!> .#
(


(
+ M ( )(

+ '

,
5
6 ;
(



!



+


! +

( A


• ,

• - 5&


( 6
• ! 5#(



6



• 3 5


6




<*


!
(


.!! 3 9<09 .#(
, &


5
6 + + U
P*$Q

(
( ( ../"!
.8 ! , ; '' (


.!' <0+
,( .CA


A11111 1 (




<7


0' #


.' ..
(


(
,( (
(


.'& 3 #
! (


( ( ,(
&
(


/ ( (
=! 2II#P*2Q
(, (
1
( '
( ../"!
.8 !


.'1 3# #
! (



( (
&
(
( (


(
A


• (
+


• (
(


• -




<<


• ,( (
( +
(


• ' 5( 6
( (



' (

(5 6
( ! (
( 1
,
(


' (

(
+
! ( (

, (
&(


. M (
A


• &


• (


• /( (
(


• ' (
../"!.8 !


.'* 3 #
! 1


& (
, (




<K


(

! ( ../"!.8 !


.'! 0 #
' (


5 76
( ' 1
5 <6


+ +
( (3 (
, ( (
( -!
-! -O,(! 5,!6O ,(!O
' ,O4(!! (
(=! 2II#P*2Q


. ( ( ( A
, ( (
(
( ,
& (
( ,
' )
/45)/46#$ (

!
.I




<N




F)2 0 0


'


'
(
! )/4



.'' 0 #
,


( (

(




<L


' . I

M ,(
5
6 (


- ( (
( ( + 11 "
1 + . < /=$ <=
< = (
.2$ (
((




, 0 D 0
0


"
.22, 9 :A
( . (
+
11
!9 (:9+:

+!9 :
,




<I


9 :
(
9 : ! 9 : ( (
4 9 :




##0


!(
'
( (


(

(
5 KL4 ,(!6,




K$


(
(!( 9 ( (
( :
( (


.'% 3 0 #
! (


../"!.8 !'
" (

'

( (%



.'- > #
! (




.'-+E
! ( (


( ( '
(
( (

(


.'-&H3 (
! ((



,
( (+ )
9 :
( !
9 : +
(.2#




K2


!
' $


• ;(
• ,(
• ,(
• >
• ! M
• ( M
• ;


• )


4 $ $ $


• ;(
• ,(
• >
• ( M
• ;


• )


! $ $ $


• ,(
• ! M


, (5 ( M
6 (




&( 0 #


'
( ,
( ( 3 (
(




K#


( (


.'-1 (
! (


'
(

( (
( (
(
! (


! (
(


.
!


5 *6
(


.'F #+
! A


A (
% G ! 2$$ 5*6A ***07* 5#$$L6
A11+ +1 12$$1*1***


>( 4&& - 4 !
5)/46 A!
' G '
' *576*I<#5#$$L6


;A


"-,(!,#$$$8 !
4 ! A
A11 1 1. R#$! 1,(R#
$!R#$,




K*


%( A


• ./)/4 A! +
A 2 ' , " 22K
!#$$7


%(A


= % ! 4= ! C ,( ! 4A , @
.2II#





K7


) $




) # 0
# =







K<


0% #


.% ..
( (


'
/


'
PIQ (



.%& 3 #
!


9 :

9:
3
7A > > 1 P*#Q
" 5 1 P**Q / F P*7Q
79 >
5,26


-
. 56 (




KK


0 I C* #$ (




KN


.%1 3# #
! (






. M
A


• "




• ; (
• (




.%* 3 #
!


%


(
'


5 22
6'


&


!
'
(


.
*<




KL


.

&



.%! 0 #


.%! (
'





'
( '

'

5 6
,
( ( '

-
( &


.%!& >
)


( , (
(
( ' 5 76
( ' (
( ( ,
(
' (



.%!1#J)
(


'
( (




KI



,
&
'

+
)
+
P*<Q


.%!*(0 .#+ .
,


.


,# F M
(
& (
,*
* A


&.# 0 0I 7&,,18


.# (0
$ 3


3
2


3
# /


.
* /+


.
7 )


.




N$




1# 0 # #


.# (0
2 4 A!
# / A! 1(


(
* A ! M


1


.%!!0 ) +. ( 0
; (


, A


• ! 27


• ,


• , (
(


'

,

(
A


2 3 #






# 0 #0
.




1 00 E7 8


! .
9 S *: 9
B *
:




N2


* #070 8


'
'
,2



! # #0


,


! ( ,
7


*)2 0 0


?


>
#


(0 # (0


E


.#
+


2 ) 5

6


)




*


2 / 1


)





.




#


# ) 5


6


)



(




(



#


W W W W
W W W W




' -




N#


5
6 ,
( (
5 6

5 6


.%!'( #
! & A


O
(
&







( ' (
,
( + +
! 3M
5 NI! 86


.%' 0 #
.



" 27
(
!



, ( O
1






N*



.

A
55 6
5 6 6
-
(



.%% 3 0 #
,



A


K , (
5
6


N ,


' (

,




,

A


• ,


• ,


• ! 3





N7



&
C
'



'

! N7


'
! & ( 1
.
*<


'




.%- > #
!




.%- ) $
!


'
27 (
.
+ .


.%-&$0+E




'
! 3
( *<R




N<


P*<Q
N<R


,

2<.

!



(
8


.%-1)20.
'



! + 56
(
; +
'
(

27 .

(


.%-*#)
!



!
.

(
' ) ,







NK


.%F +
G!


) :
G+F AG %' #$$**KA#**$


9 A !
(: C CA G
%' #$$<*L5*6A#2*#2I




,33


A111 1 1




NN


0- #


.- ..


(
( ;





S
M (
( ( (
(


.-& 3 #
)


'



-
!
-

( '



.-1 3# #
3




'
(

M
,




NL




5; ; ; <26


/
,


.-* 3 #
)




&
(


,
/


.-! 0 #
, (


(
.

(
5";86
";8
( !
(


' (
&A


• , (
• ,
• ,
• ;
• ;




NI


• -
• ,
• , &
• ;
• ;


!

'


,


.-!# #
' ( ' (


(



' (5 K6
(
,( A


• ; ( O



• (5 (
( I<K26O


• ,(
5 N6O




8 (
( A



• .

• ; 5 & &


6




L$


- 5 *
6 (
(5 ( (
(
6


.-!&( #.
! '


'

( )
(


- (


,
5
.2*6, A




• (


56 (




L2




1)2 0 # ## 00




D (
5 . 276 "
A


• )
• 5 6
• "
• ' 5


6
• ,(




L#


• ; 5 6


!




,


( <


) ,
526 5#6
( 5*6
& ,
, LL ) ,


780



(
( M .

( 5

6 !
(


7&8) 0 0


(
(
' (
( D
(
( !
( (
#<
%(




L*


( ( (
(




L7




.


!' )


! $ )>
# 7
8 C # ,
#


" ! /


• /(
• , #
• ,

• ,
• . =
• ;
• ; 2'> '>



• ; #'> '>


'>
• ! ; 2
• ! ; #
• ; 2 O; #
• , ; 2A


• 3 *$41
• 3 N1


• , ; #A
• / <1


• !


o *'>
o '>
o !
o ;'>
o '>
o / '>
o '>
o / (
o 2$4 5*6


*. 00 # 00
720 8




L<




718 D




, .
(#
(2 ( (# (2
(2
(#




• ; 2 A
2 3 *$41
# 3 N1(1


• ,3
#4
; #


• % *
• ; # A


2 /52146 $<1
• , ; 2M/! ;<$
• /





78/


; 2A


• '>
• ;'>


; #A


• ; '>


)/


• / $<1 <1




LK


'
&


.-!1( #.0
. !



'
( 5
6


! .27.2<


A"B9TTTTTTTTTTTTTTTT ?D /
TTTTTTTTTTTTTTTTTTTTTT'M (
'
( ( ,

M ( 'M '
.
M 'M
'> ' ( :


! J:


P; Q9D:


A"B9C ?4 M /= ,


LL<7(




M 'M (/
:


#!$ , # * ' C
# D* #


TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT


5A -A
A212$4




LN


A#2$$43 #


A 8 A<$41
>,%'A2$$4
- A#

0 A 8


>


56
"



;A8 V<$41>,%'V2$$4





A"B 9! M ?,(
'M /:W


!)20 #0 #0 00


.-!*(( (
- ( D



, &
,
&
(
. ( (5
1 6
;1
1 ( 5 ( <
( (
6 ('
(


(
5 6




LL


( ( (
(
-



! ,<


.-!!.0.0
,


) 526 5#6
5*6 '

!


.-!! . >
'


C
, ( ,

,
,


,
& (
(


.-!!& 0 )
'


!
1"


' (
(

' & (
(
(




LI


.-!!1 )0#59+9 #
'



' (
( (


.-!'+.
'



-
(
=
(
LK*


>(




((

& )
!
!


! 5 LK2#6
;


.-!' 5.=0


A


• ! 5
(6


• !




I$


• ;




.-!%D#
' 5 6


&
'
(
(
'

! 5
6 5 (
6


!( 0 0 # =




I2


.-!- 0
/( +


'
( (
( , (


,
( ,
(
A


• !


• ! + 1


• !


• ! (


• ! ((


• !


• !
5! !6 M


! .2K
.2<


! ( (
( (, (
(
,

M
( (




I#


<


9/ M 'M G 'M
,( %
'M ( M 'M(
M . (


(
(
( )
M
(


) (





' (
'
(
D
'
(


- J:


)20


9, 'M( ,

!
(
( ((
3 'M
(:


)20 #


9,( 3 'M

M . 'M
'M (




I*


M 'M
(
,M


! M 'M
5 6
' ( D (
M(
( , &


.( (

9(' / .#$2I<7
'M( M ' / .
#$2I<7, ' :


- J:


'#0 #0 00


.-!F(
;


(
!

5 6'



,

,
(
+
( ' 7L
P*KQ


!
,
(
'




I7



(
'
5 6


.-!,(= = #.#
!


,
526
5#6


.-!, = #.#
, 5.2N6


A5
6O ((


-
'




C ( (




' (





I<




%. 0 0 20E 0
0= ##




IK


.-!,& = #.#
, 5. 2L6


( ,
M
( !
M

5 <2;
; ;6


.-!+ 0
) ;



(

5 6



.-! )#
, 56


"

"
;

5 L<2#6


.-!& . 0 +


( (
(
' &
M (
( (
(
(
(





IN




-. 0E 0 0= ##




IL


.-!1 +.
, 526


( 5#6
'
(
(
5
6


,
(
,

'
&
! & 5.
2I6


! M ( (

(
(



.-!* " 0 +
. <2<


, (
+


! .-! 2<

.-! !




'
,




II


+




F)2 0 0 D #


.-!& #
;



!

-




2$$







8



.-!1 # +.
!



, ( 5. #$6


8
'

;
,
)
-
,
,
5 '>



&6


>1
;


&,. # E #


.-' 0 #
,


(


.-'5 #.
"


. #2 !

M
; (




2$2


,


)
!


'




&5 #0


.-'&+E++ #.
'



!
. ## "
'


&




2$#




&&.0 #


-

-


'

>
(


.-'1( ( #.
- (




(

(
7 7<2
"



!

( , (




2$*


.
(
(
( ,
( (
!
( <


.-% 3 #
)



,
( !


.-% (
!



,&


.-% #)
,&


-
( 9: 9 :
(
.
9 : (9X( :




' (
.

S
( M !

(
!




2$7


( S
JM



, (
"

!
,K

'



')2 0 # #




,
& ,
&
( '

)
( &
(
(




2$<


/


( "
& &
( ,
(
( ! (
*< ,
"


& (

,
8 +



.-%& # 0
'


(
!

( ( '
(


.-%1 #H )20
8 M(



(



.-%&(
.



-
& ! <2; ;
;




2$K


.-%1 5


(


!
& !
'
(


'
!

( &
,(

( & (
&


'
( (
'
5
6 !




'
( &
&
&


.-- 0 #
)


5 6,





2$N


.--.0
(



+ (


(


.--&. (
'


,
5 #<6!

& !
(
5 6 .
M
!



.--1
'


& ,


.--*
'


;
5 6
! (



.--!=G
'


!
M







2$L


+
#$




































) # 0




2$I


0F $ ) #


.F ..
./" !5./"!6


( '
2I7$M ) ! . & 5!&
2IIK6 ./"!

./"!
& ) A >
! P*NQ ' / ; P*LQ '
/ ; P*IQ ' ' P7$Q


./"!
) ,G M 4-<#
4 ! / P72Q! M
8 ; (
(P7#Q


/ ./"!
./" !./"!6,
./"! 5../"!6 &


.F& 3 $)6
../"! (


'
( ../"! A


• 5 6
• 5 6
• ' (


5 & 6
• 56
• 5 6


, ../"! ./"!
A


• "




22$


• ,(
&


• '
• '


((


. ../"!

(1
&


.F1 3#$)6
../"! (


,
(


../"! &
( (
, ( (
& '




. M ../"!
A


• ; (
• (



• ' (



• /


(


.F* 3$)6
../"! (


(




222


,( (
&
& "



. (
&../"!!


( & (


! 58 !6 5 2$6 ../"!
(
../"!
( .8 !


/ (
& ../"! &
( &


.F! 0 $)
,../"! .#*"






&1 0 00 0 0
$)


.F!.
, ../"! &'


( (




22#


!
( (


(
+ (
& (
+ ../"!,

& &
( ' / ; .-!" 8'' '
' 3 5365)=6! ;
.
& ( " 8' ' ! ! /
' '3!,! (,G '

( ../"!


• ' 56 J




• ' 56
../"! 56J
(
(
../"!


• '
J ' 5

6 ( ../"!


• ' & 5
6J ' ../"!


• ' & J
& (




22*


.F! (. )
, ../"!


,
!



../"!


.F!& ( )2
, ../"!




A ; , N
1

#


.F!&


,
( (
, ../"!
& !
(
( (
../"!




227


%)2 0 20#2 $)
0 0 % ! !
& !




.F!& $+
'


+ "../"!
+
! (




22<


.;$ 9)20


+
,
& (
(


+


;
& ( ;

, (


.



& ,

../"! (
&


> 9


,
( ,

,
,
+


.


,


)20


' ../"! ,
../"!




22K


!
../"! '

5 ( (6
!



.F!&& .D
../"! &


(
& ../"!


M(


!
( $ ,(

( ,(
(
, 9: ,
( ../"!
(
( , 9:= (
../"!
( ' (
,
(


$K/


/(


0/ O


) A2#


(




22N


.F!1(


5 6
-
!
(
, K
,(!


(,
../"! (
3

, (
5 76 5 <6 '

../"!,




. ../"!
.
!


' '

'
"
1 1
(


'

;

!
= + 5
(6
../"! ,




22L


( (( 9
( ( ../"!:!



, (
../"! (



(4
5 ( 2# 2# 2#
( 2# 6 )





%

( -
'



!
( ,/ Y#;




22I


$K&/


/(


0/


) ( /


,
( ( "

%
(


!


.F!*# $ )
& (


5./6
,> M ! 3 ;
9
:P7*Q' $ '
$ $ .
(
' $
( ) $
../"! ,
, ../"!
















2#$


,
../"! (
, ( (
(
,L ../"!


-)2 0 $)0 00




../"! & (
(
. $ $


' (
,
(

(
,
A


• J
• J




2#2


• '
J


• (
J


' (

(
5 *6


F)2 0 $)0 009




' ../"! (
(


, ( (


(




2##


( &
+ . ,2$
& $
YK

! (
5 6
5
6 , 5
6 (


,)2 0 $)0 0 09 9




(




2#*


$K1/


/(


0/


) ( /2


,
, (
(
"

' + (



' (
,( (
(


'




, ../"!
'
&
( (


.F!!+ $) (H# $
!


,/ Y*
&
(,

(
( 5=./6 =./





2#7


8( (
' ../"! (
( / ;
/


,
&
,22


'
.
( 9. : ,2#
+ (


, ( (



( (
(
../"!

5,2*6


'
M
,(
( 5 *6!
+



( ../"!
(!
(








2#<


)2 0#= 2




&)2 00 #= 2





2#K


1.# 0 #





2#N


$K*/


/(


0/ - (


) ( /* 7


3 (
( !
(



, (
( , (
!
"
../"!
( ' +
( ../"!


-
%


.F!! 00#



( , , &
, ; (, ,
.#7


/.#


! (
5 6
1
3
!
( & ',




2#L


22 * *
=./


*00##




&/ D .


, &
3
& &
&
! &
& 5,2<6 =./




2#I


!00# D




. &
=./


'! % !( 2


!
(
. YL,2K9-
: &

'
(
' 2


'! % ! 2


! & (




2*$


,
' 3,
& A


2 ,
# ,



* "



7 , (


1


, &
=./ &


' &
&
5,2K6


'##







2*2


1/.3


, ( ,
& !
( '
(
& =./


'! % !( 2


'! % ! 2


' (
=./&


' (
( ' &
5,2N6


%.0




=./
( ../"!




2*#




&*( #


.F!'#
=./


=./ (
=./ $=./!
( (
!
../"!
=./


,( =./ (
(
$(

../"!'
(
'
( =./




2**


526 (
5#6


# =


( ( ( (
=./(

. (
../"!, (
($ .
$

8 ( (
;
C 5
6 5
(6
; (



#0 )


=./
../"!
'

( (
( (
(



( (

5 76 5 <6 5 N6
5 L6




2*7


( =./ ../"!
(!
(
=./


$K!/


/(


0/ & (


) ( /# *


8 ( &
, ( (
, (


" ../"! '
+ ( ../"!


- (
%


.F!%(0 0$ .
, ../"!


(
( -

'
(
(
( '
(
'
(


,

" 5 *<6
, " (




2*<


(
=./


$K'/


/(


0/ (


) ( /# *


' (
,
"
! (
(
"


" ../"! '
+ ( ../"!


- (
%


' (

(
(
! & (
1
( , &
O

(
(


, & ../"!
(
!




2*K




$K%/


/(


0/ & ../"!


) ( /# 7


, , / YK
& ( 1
'
& (



5 IK -
../"!6


,
+


-
(
%


! (
../"!


.F' 3 0$)
! ,/ YN &



,
526 5#6
5*6 576
(


"
& , / YN !
../"! ,/ YN
( (




2*N





' (
../"! (
,

&
../"!


.F% > $)
; ../"!




.F%++E
4( ./"! ../"!


!
, ../"!

./"! , (
(
(.

(../"!


.F%&0#)# $
3



./"!

( !
../"!

'
5 N6 5 L6
../"!


.F%1 D ..; 5#+ +
! & +


& ,&




2*L


( ,(
../"! &
,

. &

,& ../"!
(
(


.F%*
, ./"!


(
,
( (
( (
" &
, ../"!(



.F%!"< (0$ .
, ./"!


!

.
&
+
(, (
../"!
M(


.F- +
G!


2 " 8' 5#$$76 . A !
-**5N6O#**#7*


# - 8 G ( " % G; 3 , 5#$$#6 )
,/A , >! 3 ;
M ( G U '
#L5<6O#7L#KN




2*I


,


2 ' ' . / " !
,
A111(1;1,1./" !
,




27$


0, + #


., ..
8 ! 58 !6 (




' ,G
9
+ ( :P77Q8 !


4( (
8 !

,


(

)


P7<7KQ,
9 : P7N7LQ '


P7IQ


,
8 (


(


, 8 ! &
, G >! 3 ; '/;
; ' 3 5)=6 8 !
( . G 8 ! (

8 !P<$Q ! >! P<2Q '/;




272


8 ! P<#Q '/; ;' +
' ! .( P<*Q 3
5)=68 !,( 4;P<7Q


. ( 8 ! (
.8 !
(


.,& 3 +
.8 !


!

'
(



,.8 ! 8 !
A


• - .8 !
• ;



• -
• "


(
• '


((


.,1 3#+
!


.8 !
.8 !

'
& ,

M

(
'




27#



(
(


.8 ! &
&
(



. M .8 !
A


• ;
• 8



• 8



• /


.,* 3+
!.8 !



.8 !


; .8 !
(
' .8 !




.8 !
(


.,! 0 +
, .8 !


+ .8 ! (
( (




27*


.,' 0 +
, .8 ! . #< "






&!20 000 0 +


.,'(3 ++E
. .8 !


,(

+


!
, ' -
, 35)=6P<<Q 5.#K6
,


, .#K
' 1

.8 !'

&





277




&' (+0 . #)+0
07 0H" .8


' M
'
526
( 5#6 5*6
8 (



,
( '

=
5 *6
'




27<






,
.8 !'

.8 ! , (

.8 ! ( ((
&


.,'&.
! .8 !



' (

A


• ! (

• /

• ! (
• ;
• ;

• , M


' M (

'
&


(

,

5




27K


((( 6!


' 5
6


.,'1)


.8 !,(

+ &

P<K<NQ

.
+
, &


C



.,'1 0 #
- &


.8 !
( M
.8 !, ' !.(
P<*Q &


.,'1& $+
'
.8 !, '
/ . (
(

& (
. .8 !




27N


.
.8 ! ;

'
'




>


! ' ! .( P<*Q

( !
( ,
A


• =


• 8




! (
! (

, A



• "
• .
• /
• " & M



• "


.> 0+0


!
( !




27L


& ,
A


• "
• ! & M



• "



• "




.;$ )20


+ (
,
&
+
( ( .8 !,
(



.


,
,


)20


' .8 ! ,
.8 !
(
(
'
(
5 ( (6
.8 ! !






27I


#


' .8 !

, +


.,'*(0
- (





.,'* (
, 5 K6


,


, (
56 , (
,



! ( (


.,'*& #0 (


.8 ! (! (

( , .8 !
.8 ! ( 5
76 5 <6

(
O
.8 !


.,'*1 > #52 (
, (


' (
(




2<$


( (


,
9 (:
9 ( : ,
(
& M, (

( " ((
( ((
( !
(


( , (
(


.,'** D(


(
( .8 !
( ,


.,'*! (0)>
% &


,
.8 !


.,'!#


.8 !
$ '
+
,
,
(
P<*Q




2<2


! (
(($
,
!

../"!

5 2*#K6' ( (
+ .8 ! (
, (
( .

( (


.,'! =:.$
,


5 76 5 <6
5 N6 5 L6 '
5 *#68M /
"5 *76 5.#N6




2<#




&% 0+ C.$9&,,,
?C = 9&,,*


, ( (
(
& 4
(
. .8 !

( 5.#L6




2<*




&-+ C.$ ?C = #


' (
5 6 , G
M 8 ! .( P<$Q , 2L
.8 ! (




2<7


-+ 7


!U ;


2

J


4

D


! ,
#


"
A



• '
• ;
• ! 5(


6
• .(1


#


J


"
!' Y2


*

J


-


" A


• %
• . 1
• .
• ' (
• ' 1
• ;
• 4( ((
• 8 (

• ,


7


J



!"-




2<<


'
A


• - (
• !
• -



• 4



• (








<



J



& M J


" A



• (
• 8(
• 4


,
U Y2N,


K


J


' &
(


N


J


4


L

&
J


4
.A


• ' 1
• ' 1




' &




2<K



,


I
PQW



J


'


"
A


• 1
• 5



J6


• ;1






• ,


• ;1


2$

J


'
3

M
(J


22

J


' &



- & M
"
A


• !

• .
• /
• ;83


'




2<N


2# J


2*
-
J


-
,

J

J'
(1 56



27
,

J
! J J
)J


-


&


'


-
5
6
M


- &



2<
,


J


!

(
A


• , (
• / 1



• ;



• ' 1






2<L


2K

J


,
K




(J



& J


" A











2N


(J


' (


• -
J


• - (
(J


• (
J


2L


J


-



8

5(

6J


"
A


• .
• "
• /




2<I


• /


.
A



• -
• .
• ;
• )


2I
& M
(
J



(
J



& M J


• &
J



(
J


• J


#$


( J


-

& .
(


' ( (
5 %!86'
(


#2



J


- & M



##


(
J


-

5
((
6




2K$


#*

J


" A


• ,
• "
• /
• ,


#7


( J


-
-





' 1 /.(5.#N6,
G M ' !.(
.8 !
5,2I6




2K2


F<E00# &


7 : 08/
• (J
• &( (J
• 5 ( 6J
• - J
• J
• 5 6


(J
• (


5 6J
• ( 1 1


(1J
• J


)E07 #8/
• J
• - J
• J


1J
• J
• &J
• 9 :J
• 5 6


J
• J


3 /
• - J
• (J
• ( (56 5


6J
• J


78 /
• - 56 J
• ' J
• - (


J J
• - J
• J'J
• J
• J



# $%& '$ (#)#*


$! %




2K#


/ 78/
• ( J
• J
• ( J
• J
• J


/.00 7 08/
• J
• 5 1 6


5 +
6J


• 1 J
• J- J


56J
• J


5 D / 0/
• (



• ( 1J


J
• & J
• J


5 D //
• 5 6 (


J
• J


J
• J
• J


5 D / 0 #78/
• - J
• 5


6J
• 1 J
• J


5=/


1 J


1 J
• J




2K*


.,'!& +(
, .8 !


/
8 !
A '(- ,-
-. '
!.(


( *


!'( M ( ,

5. #I6 3
5. *$6 .

5.*26 '(

&&




&F ( /. 2




1, ( /




2K7




1 ( /( # #


( *


! 5.*#6
(
)('(-

'





1& *


( *


! 5. **6
'( &




2K<




11 ( !


, (
1 / ( 5.#N6

5.**6

'



.,'!1 D(


.8 ! (!
.8 ! A


A


2 ' J


# ' 3,
1 J


* ;
J




2KK


8
&


.,''(0$ .
!


& 2$K<*
&

,
&
, .8 !


.,'' #)(0.#=.
.


) " 5 *<6
;

(


.,''& G #5G #
8


!



.,''1 .$+
/!8,P<LQ5,#$6A


&,.$+ A!-BA,B


.0 , (


$ -




+ 8


# !


! /!8, (
&




2KN


! (

&
&
( ( &
&


.,''* ? $ .
;



C
& &

(
5 76
5 <6 5 N6 5 L6
../"!5 I6


, ' !.(
( 5,#26
( 5,##6,
.8 !
+
,
.8 ! O
( .8 !




2KL


&D+ AFFB


8
!


5 6


8(
5


6



"


5

6


;


5



(6



4


,


"
!J

,J



>
.



;
,
.






&& +AFFB


Y 8 '-Y
-


"
;


,
5 6


,
!


8(
4


'
8






.,% 3 0+


.,% ( +0
.8 !


&
& .8 !8


9- : 9 :
( ( ;

&






'
&


.,%& $)
- .8 ! .8 !


../"! (




2KI



2# ../"!


.,- > +
! .8 !




.,-++E
; .8 !


..8 !

! .8 !

;


.,-&+000 )#
C .8 !



.8 !"
(,

' -,5.#K6


.,-10 ++E
.




&

. 5 76
5 <6 +
(




.,F +
8


2 ' ! ; ' ! .(
" !%A ; ' O #$2# ' !
; ; ' 5 ;'6'
/ ; ( ; ;




2N$


5 ;'6 ; % "
/ /!


,.(!


2 > ! 3 ; 8 ! ,
A11 1 !18 !1 Y7


# > ! 3 ; 8 ! ,
, U
A11 1 !1,1


* , G .( 8 !
! ;
A11+ 1.(T T TT8 T T!
TT! T;1


7 3 5)=6 8 ! ,(
A11(11 1


" 8 !


2 '/; 8 !MA


• .' 8 !
A11
11 1.' /#$$N


• 1/"
A11
11T/T8 !T8 T 2#

• , G " - A 8 " ,


A11+ 1 T


• ,G " - A8 " ,





2N2










2N#


0
0


. ..
)



'
P<I K$Q PK2 K#Q
'>

PK*KKQ


!

&
, O (

('
(

( !
(



%
& 526
5#6 5*6
576

,
(


. ( ) . -
! 5.-!6
PKNQ!
G PKLQ
A 526
5#6
5*6 ( ( (




2N*


576
5<6 5K6

,
5.;';6


%



.& 3
, 5.;';6


(
& , (

(
, (
5PKIQ6


.1 3#
, (



!
&


.

&
.;'; (


!


PKLN#Q .
.;';
(





2N7


. M .;';
( A


• O



• ; (


.* 3
, .;'; ( &


A


• , (
• , 5


6
• , 5


& 6
• ,
• , & 5


6
• ,


' &
.;'; (


.! 0
' .;';


(
5 6
5 6


.' 0
, .;'; ( . *7 "





2N<




1* 0 78


, & .;';
+ +

('


(


.'


.'
, .;';


(
A


• %
• !
• ! ,


5 & 6

(


• .
• "


../"! ../"!




2NK


• ! .



• ! .
+ 5
6


• !


• !
&


• +
• ( 1


, (



• !
&



.'& ) " 3
, .;';


& ,


& ' .;';

5 76 5 <6 (
5 K6../"!5 I61.8 !5 2$6


,

,
! (
'




,
A




2NN


• ( J
• ' &


o &
J


o J
o (


J
o !


& J
• !


5.-!/!)-"6
• !


& 5" 8'' '/;6 & 5
!!/'6 5 .-!6J !
.-!M


, (
5 76 , ( ,(
!5 K6-
(
5 76
5 <6 ! 7




,
&
&



8 ;58.;6


.'1 3 (+
' 8.;



8.; .;';A


2 . 5 6




2NL


# !


* !


E


" 22K2#
8.; .

,8.;
9,
:


+E # 0


-
!DE!! "F: 8AAG
H 1 IF;J

8.;!
( !DE!!"F:


, O
,#*
#$2# .
" PN7Q


&1$


. 0


!3'1!!/'"N<A#$$I H
1


;






'" K$K$22A#$$<
!3'1!!/'"K$K$22A#$22
*


5 K

-


'





2NI


'" K$K$22LA#$$K ) ") LALA7
78AA:
- '


8




'" ,8K$LNLA#$$*




!
-







2<


'2<##*2A#$2#


'2<##*#A#$2$


H !
$
'


; 20'





; #
0


'27IN2A#$$N





! )



,
(
.,!
./"!


'" K$K$2222A#$22 ) D
-
-

!
" !


-




'L$*KI02A#$2$


!!!
-

7 5
- 8 F


-






'" ""0,8.M H ) 3 %
")

'" 1'




, A .
(




2L$


(


5 0#


!
.;';8.;
"
5 N61 5 L6.

A


• !
• &
• ,




/ 8.;
, ,


5 A V*$R
*$R 1 7$R6 ,
1

A


• ) A


• ,( A (


• ; A (


& ../"!


8.;
& 8.;




2L2


.'&)
,.;'; (



, 5 N6
5 L6../"!5 I6


.'& #
5 N6
../"! (
!


8.;3

8.;


'
'
0 +
56 "

'
+



&
,
1 ,

,
!
(

)


.'&& #
5 L6


)

)




2L#









( (5 L<L6


) .;';



5(
6


.'&1 $)
../"! 5 I6


,

!../"! (
(


.'&* =
' &


!
'
'
.
M


- (

,
&

, (
!




2L*


,


.'&! ?
, &


(

3


.'10
,



PN<L2Q , , ! /
PL# L*Q

,


! .;';
(


(
, (


.'1 (78


, (
= .;'; (

5 ../"!6 ,
&
.;'; 1
../"! (


' ( ../"!
(
(
. I../"! *< "




2L7


.'1& 78
! .;';


1
&

.
5 6
5 6,
( M
. 5
../"!6 &


.'11 0
$ 3 .#


!
( (
, ( (
( ,
.;';
+


)


!
, *<
" "
,
'
&
'
.;';
(

"


, M

(
S(M 5
6
( 5




2L<



6



,
! (
( %

-

(


!

5
6, (


0




& .;';
,




5.00


! (
'

1 "
&
8
(




2LK


.% 3
.;';


&.;';,
&


.- >
! .;';


&
(


.-++E
; (


.;'; (
& (
&



.-&$ #" )#$ (
- .;';


, .;';
227 ).;';


.-10 + #9).
" .;'; (


(
-

9:
( ,


.-*) =(#3
" .


(
" &
& )
5
6




2LN


.F +


• !3'1!!/' "N< #$$I " Z -
! A
A111 1 1N<


+


• .-! #$27 " 8 ' ; ; ! A
A11 11 1
1 1#$#7IK Y*




2LL


./00#
#$






!" #$ %&$"'"$



%

( ,
+

&


; ''' ( ; ''
( '
(
2#
2*



&
& '

+ 5 6






2LI


0& .00 .#


%
& !


&


,

5.;';6 5) D 86 )
#$$$


"( = 0


.#N#$$$ #A*7!/ -/
,/ . !
7A*$;/!
- NA$$;/
5; !6 ! ; !


! ; !-
! LA*$ ;/ - (
*$ -


, -
)

214 -
< 14 , -
<


.#&$05( $ #


, ( PIQ
+ ) 0 !PL7Q


! (
! <14 2
14




2I$



(

5214
<14 $<14 2$16 ,
+ (
, (
( 214 <14 2
14 <14
' ( 214
214
5 6


(-M
; !

. -M
PL<LNQ


; !
K<KKN
PL7Q!
; ! #N
!
2#
!
(
(PLLQ


,
PL7LI
I2Q;- ; !
; !


, .;';
22 (
; ! M ; !,
; !
!




2I2





.&
; !


( .;';5,#76'
A


&*(


- ( ' (


! %


; .


C


; 8(


; '


4








, .;';
'
, ( (


.&& ) " 3


.;';
5 76 ; !
'
5 <6
(


! ; !
(5 K6 (
.
5 <6 (




2I#


; !


, .;';
.8 !5 2$6 M
; !'
; !


.
5 6
5 1 6!
5.*<6




1! . E
0


.&1 3 (+


58.;6 '
8.; .;';
"N<PN*Q
; ! , #* '
8.;
A 9 $
!!E!D D "F::! 8.;




2I*


5 L6


,8.;
.;';5.*K6




1'(0 00


.&* )
,.;'; 8.;! M


8.;
.;';
8.;, ; !
.;'; ; !

.;';


! 8.; .;'; * ; ! <$

(




2I7


.&* #
, 5


N6 F 5,
26
( ( ; !
( , (
M
; !
(
( ,
(
(
5 6 ,

,#


! SM
, #
!
! ; !
,#<


&! 0 ##0
#00


Pump A
Issue Heuristic


Violated
Recommended Changes or Actions


Pump can start infusing with
the cover closed but not
locked.


Prevent Errors


Feedback


Pump should have a sensor on the lock, and not just
the cover, to ensure safety given the high-risk
nature of medications such as narcotics.


Cannot change the delivery
parameters once the pump is
programmed and running.
Users have to re-program all
information and any shift
information is lost.


Flexibility and
efficiency


Users in control


Pump should allow users to adjust parameters in the
setup menu once the pump is running. A code or
key should be required.


There are two different task
sequences associated with
changing a syringe depending
on whether the same drug is
continued or not.


Minimize
memory load


Task sequences for changing a syringe should be
consistent regardless of whether a new syringe
contains the same drug.




2I<






Pump B
Issue Heuristic


Violated
Recommended Changes or Actions


Pump does not require the
barcode to be scanned. Manual
drug selection is always
available.


Prevent Errors


An option should be available to make the barcode
scan mandatory prior to loading the syringe.
Scanner should detect and indicate a faulty
barcode.


After the barcode is scanned,
the drug name and
concentration can be manually
changed.


Prevent Errors Once a barcode has been scanned, the drug menu
should only show the scanned drug. All other drug
names should be eliminated.


Pump does not prompt users to
systematically review the
settings before starting the
pump.


Prevent Errors On the Run screen users should be forced to
confirm each setting.


There is only one lock level
that provides access to all
functions.


Prevent Errors Create at least two lock levels. One that unlocks all
functions and one that unlocks everything but the
clinician bolus so that ward nurses cannot
accidentally give boluses.


When the pump is unlocked
with a code it remains
unlocked for one minute.
Patients could tamper with the
pump during this time.


Prevent Errors Pump should automatically re-lock once it starts
running, or after 30 seconds of being idle during
programming.


The 4-hour limit does not have
fixed units. Users can select
mcg/kg, mcg, mg/kg, mg.


Prevent Errors Units for the 4-hour limit should be fixed as part of
the drug protocol.


Pump C
Issue Heuristic


Violated
Recommended Changes or Actions


Button key press is not visible
to user right away.


Informative
Feedback


CPU should update screens much faster to prevent
users from selecting the wrong button.


Buttons on second screen should be carefully
placed so that selecting a button quickly twice in a
row either (a) selects nothing (i.e., no button
underneath on second screen) or (b) selects a safe
second action that is easy to exit from if desired.


No clear way to exit the Bolus
Dose screen without giving a
patient a bolus. The user must
press Cancel twice to exit. The
pump will not accept 0 mg.


Reversible
actions


Users in control


Minimize
memory load


Provide a clear exit (add “Exit” key to bottom of
screen with a screen asking user to confirm that
they do not want proceed with a bolus). Allow the
user to enter 0 mg as a dose and again confirm that
they are not giving any dose before asking user to
close and lock door.




2IK


.&*& #
. ; !



5 L6 ,
& ,
5.*N6




1% # #


.&*& 0 #
- 526


5 65#6 (5*6
5 L<#6 "

( A


2 ; !


# 8


*


7 , (


,
(




2IN


,
,
. *L . 5 ; 22$6
5. !%, 6
52#*6




1- 00 0 0 0


) .;';

,
.*I




2IL




1F. 0 #


& ( !
. *I . 7$ !
5 L<76 ( (


" ; ! &
' &
; !
8

, ; !





2II




A"B9TTTTTTTTTTTTTTTT'M ,(
M M + *
( 8 M (
'M ' ; !M
. M
DM '> ' (
, '>
:


! J:


A 0 B (### M3P Q


A"B 9C ? /8 NK
3
K# 27 *NL[
22$1N$
5K12$ M 6 '>; !


'M + /
M(


A 0 B/


A"B/C (?'M(


*,.00 #


; 5.72.7#6
(




#$$




*. 00=E 00 #




#$2




*&. 00=E 00 #


, .;';
. .;';
,.;';

,


'


.
1


, A
.;'; O .;';
& ,
( 5 L<2*6




#$#


.&*&& #
) ,


5 L<L6 5!
!6 (
5. 726 ,


.
5 6
,
!
-

. (
5.7#6
, ; !
& ( !

; !


, &
; !5
LN26 , ,



U (
-
(
,(
.;';


8
"
,22
; ! 5, #K6 - &
(




#$*


&'. # 0 # #E
#


;!


(0) 0 . #


' 5
6


)
5


6


; 1





;

&


) 9( :
2$1


;




,
$$
7##4,
&




(





)
(









(


3
;
1



)


)
,


;




;%


(0) 0 . #


Barcode scanner difficult to
activate.


)
5

(6


/

;
1




#$7


)


)


;
) (


;


;



)
2< ; !

; !


;


)


)



;

7


"

(


)




;

7


)


)
,



;


;


(0) 0 . #


'
9! /:


)
9 :

) 9! /:
(


;




;


) $#
#

)


' #
2$




> )


;
1




#$<


'








; (


)

(
(


(
'

2<


)




, .;'; , #K
(
8( 5

6
& ,#N


&% $ #


;!


(0) 0 . # $ . #


;



&


)
9( : 2$
1


;












,





"
#




#$K


$$7##
4
&



(



& "



,(












(


3

;

1




"
#

&
8

(




;%


(0) 0 . # $ . #


)



;

) (


;

( M


"
#

&
8



,(



)




;


7


"
#

&
8




"


(


)





;


7


"
#

&
8








#$N




;


(0) 0 . # $ . #


'
9!
/:


)
9 :


)
9! /:

(


! /



,





8!




; !


;


)
$#
#

)



' #


2$




"
#

&
8



(


>


)



'







;

1


"
#

&
8




; (


)


(
(



'






"
#

&
8




#$L



(
'


2<







- .;'; ../"!5 I6 5 22K#76
& M .;';
(
,
( .;';


'

; ! !


, M
; ;!;%
M
3


.&! (78
, ( ; ! .;';



+

" ; !
&


3 (
.;'; ; !




#$I


,
& -
; ! (
8.;,.;'; ; !
,

,.;'; 5;-6


' & (
'


'




.&' 78 )
. ;-


.
+
!


&


.&% 078
$ 3 .#


. ;-
( .
(

PI#I*Q ; !



)



; ! / .;';




#2$


,

, +
'
S(M 5 ; ! 6
; !(
9 :
; !
; ; !
(
(


0


,; ! &



5.00


" ; ! 9 :
; !
!



, 3




#22


01 #
.#


%


'
,

5.8 !6
5../"!6


.1 +0 /+
,



5.8 !6 ( 5 *6
#$$K


0#5+ (


G *2 #$$K 7* +
5'>6 (
;



+

,
!




,
( (
%
M
,




#2#





,
(
'
+


,
,
,
! ## #$$K 9
:


.A'/; .' 8 !/#$$N!
A1111 1.' /#$$N


.#1 0#0


'/; (


& .8 !
(


; .8 !

' 8 !
'/; 8 ! 7
'
/ & (
& '/;
8 ! (
(


, '/; 8 ! PI7Q
8 !'/; .8 !
( '/; 8 !
. ( 5 76 '
5 <6) , 5 L6,




#2*





.1(3++E
, 8 ! 5


6 ' -,5.
#K6 ' .8 !
A

( (

(


.1&.
% A


• ,
• ,
• ,
• !
• ,
• , M
• !


! (
;


.11)
' .8 !


(
5
6,


' 8 ! '/;
A O
O


!
' /
8 ! 8 !
& &




#27


.1*(0
, '/; 8 !P<#Q


A


“A woman in her 40s died last week after she was mistakenly given a lethal overdose of a
standard chemotherapy drug while undergoing treatment at the XXXX Cancer Institute
Instead of receiving the intravenous drug continuously over four days, the woman received
the dose over four hours on July 31 from a pump that had been programmed in error. She
died Aug. 22 at the University of XXXX Hospital from complex causes, including a failure of
multiple organs, as well as widespread internal bleeding.”


From: XXXX. We cannot eliminate human error. XXXX Journal, Thursday, August 31, 2006.


,
5. 7*6 ,

( (




( (




#2<




*1 C


+




' 8 ! '/;
A


• ' A


• ;
• '
• 3
• 3
• 3 (





#2K


• .
• %
• / ' )








• ! U


• ! (


• ( / , !
;


• ! (


• !


'

( 5.
776 '

#7 .77
,
.77




#2N




** 0 0 9
9 #9


'
,
( ( ,

'/;8 ! PI7Q


• ,




#2L


• . Y2
M ,
5<#<$6
576 57<<N146! #LL
41
,


• 3Y2 #LL41


• 3Y2 (


• 3Y# (
3Y#
(


• 3 Y2 Y#
<#<$


• 3Y2


• 3 Y2
7


• !


• ,
3
M


• , 3
,3
,


• , ) /3Y2

, 2#41
#LL41 #7




#2I


.1!#
,


, (
8M /> M 5 2$K<26

, 1 .
7<




*!+ C.$ ?C = #


! G 8 ! ! ; ,
( !
G 8 !! ;,
,#L




##$


&-)20 #EL+


!U -


#


3Y#(


W


*
J


A


'
#7



W


W W W




&
'( 5 2$K<#6


' '/; 8 !
& !
526 5#6
5*6


78


• 3
,
(


• 3 Y2
O


• , #LL 4




##2


• 3Y2 5
2*$4
*$41 7
IK6


7&8


• , 5.7K6
#7


• !
41#7




*' $


• , ( &
( 3 Y# (


• ,(



• 3Y# 5


2*$4
*$41 7
IK6


• , 3Y#




###


• , M

(
&


5*6 00C #


• ,

,
(


.1'(0$ .


,

2$KK

(



.8 !.
'/; '/; 8 ! PKIQ
9 :

( (

"
5 *6 (
'
./"!


' 8 ! &8 ! 5,#L6
(
5,#I6




##*


&F)200D+


8
!


5 6


8(
5


6



"


5

6


;


5



(6



4


,


"
!J

,J



>
.



;
,
.


/
!';

!';


/ 8

+





)


&


4



,(






'




1,)20 +


Y 8

'-
Y


-
"


;


,
5
6


,
!


8(
4


'
8


2 /
!';
!';


2! $I1$I1$K $*1$21$N
,
!


/ ;




! &
.8 ! , '/; 8 ! PI7Q


.1& .# 0
7$)8
. .8 !


../"!
(
. (../"!
.8 ! (
7
*
../"! (




##7


0) #0


. *5 6
.8 ! 5 2$6


%
&


!
( &
5.7N6)(


& (
../"! ( &


.#*#+ ) #0




*% #00


.1&.
, ../"!


# ,
(

,




##<






$


, (
5,*26A


1 2 00


)2


0


'A!


"A !


> :)/


'A


"A ' M


. 0 /


'A (


"A (
1 ((


/


'A 8 (
(


"A (( (
(


)E0/


'A" 1


"A4




##K


,





.1&&
!



../"!


, ../"! A


3 /


• .
• %


# /


• 3
• !

• ;


• (
• 8(


$K/


/(


0/ O


( //##$$N


/2#A$$27A$$


$"/


8




##N


- A 5 6
5 6 5 6


" (
5 N
6


C 1


O
(
(


.1&1(
! (



5.7L6




*- 0 0# 0
#00


!
(




##L



& (
,
&
(


,( &

( ,(

M
M &,

(


% (

M


- (

(


M


,(
5.7I6,

& A526 ( (
5#6




##I




*F 0 0




#*$


$K&/


/(


0/


( //#<#$$N


/LA$$02#A$$


/ 3 A


!( (


>


) (
(

(
4



8


-


8 (
O


.( O
+


3 A( ( M
(


.1&*# $ )
,(


,*#




#*2


1& 0 000


,(
( ,**


110 0





#*#


! (
,
,*7,*<


1*.# 0# $)




1! # 0# $)





#**


$K1/


/(


0/


( /G2<#$$N


,ALA$$2KA$$


/ 3 A


8(





.
( ,
(


C
,
,



O
(



,


3 A(


.1&!+ $) (H# $
)


( 5,*K6




#*7




1'0 # 0 #





#*<


$K*/


/(


0/


( /G#K#$$N


/27A$$2NA$$


/ 3 A


!(


../"!


. (

,
( M


. ( ( M


!



!
&O *
& L


(
,, 5 I<K26
( 5,*N6




#*K


1%0 #




,(
( , (
( ,
&


.1&'#
. ( (



( ( (

( ! (
,*L




#*N


1-0 $)0 0 #




! ../"! ( ( (

' (
(




#*L


$K!/


/(


0/ & (


( /G#$#$$N


/IA$$2#A$$


/ 3 A


!(


../"!


.
' (


. ( (
( ,
( ,


! (
,
+
(


3 A,(
,
( (


.1&%(0 0$ .
% (



( ,( "
5 *6


' &





#*I


$K'/


/(


0/ (


( /! 2N#$$N


,A2*A$$2KA$$


/ 3 A


!(


../"! &


. " 5 226



'
"


!
( 526
5 " 65#65*6
,


! (




3 A ( ../"!


%
, / YK ( ../"! 5, *I6
(




#7$


1F 0 $) 0 0







#72


$K%/


/(


0/ & ../"!


( /! *2#$$N


/LA$$2#A$$


/ 3 A


!(


../"!


. "

(


. (M


- (



, &
526 5#6 ( 5*6
(


% 2$
5 IK -
../"!6 ' &

(


, (
../"! ! (
&
../"!


. ../"! (
526 ../"! 5#6 (
5*6 ( 576 5<6




#7#


5K6 (
%
(


, &
(
(
& M ( ,
(
( (
.8 !' (
( (










#7*


+
)


,( "
" C
' ,
+ ,
" "



, ( +


(


2 =G> /+D #
#A> O#$$7


# / . 0 / 9
#9 A!; O2IIL


5 D :)
• ,. " 5."6O


, ! & 5
6 + ' " 1
0 ) " 1 ."
, C 5 A11 6 &
. " ."
"


• 'C 'O


, & 5
+%) <!) )
=


• ,' ". O A11


,)=&


• , ' ! . "
! O #$27




#77


'
. " !."
(


< (
2 , .-!

&
! A


A11 11 1
1#<IN7L


# , &
&
! A


A11 1 11 T1T
1T T JV2


* , 5 6
'
.


>25; . 6 A


A11 (11! J V1'
1R#$. R#$ R#$CR#$2#


># A


A11 1 11#$2*1$<1'
#.'3!4#$2*T$<T2K





#7<


+
2 ) / . .#A,3 !;O


#$$$
# %(C83 ;C. >%8%! G" "C!B


; /+ 8 A ) .#/
0 0 ) !
0 #$$7%,5226A2KNL2KLK


* !%! ,! ( ! , ! - D C C
8!A)29 E /
0 ".0 N K D
) #$$N'5K6A7*77*I


7 - ; 4D 8 % 8 ! ! A "
I 0 0 / 0 $ O
/ #$$#!522KN6A)#N2


< 8/%,C8 G-A #
G # .#
0 ! 2III%,5I6A72272<


K G G,A"9 )= )
0 0 D #$2*F5*6A2##2#L


N .-!A( < # ( . =
00# # ) 50D $
(('#O#$22


L ) 7)8
P A11 1 JV @ V Q


I > =A /+D ##A
> O#$$7


2$ 3-!A()# #A%%(O#$$#
22 ) ! ! . !/ "-A #


*',M0=M)20 50 A
!!. !/ "-O2I7N


2# "43- A A!"O2ILL
2* /G/8 %A" #/ 00A 8


;O2IIL
27 3!A #A,@.O2IIK
2< ;A 0 # !


#$2$*5<6AK<NKK<
2K G%384 -/;(%A $ 0/


.# ! 2INL*F5K6A*II7$K
2N 444A)0!!0 ! !>D


" 2II7&%&5#*6A2L<22L<K
2L 4 44 % ,! 4 3 4 !C 4 !8 % %! 4


3 G;; A 0 D
0 / $ .#$ " 0
2II21&*5K6A*NN*L7




#7K


2I GC ( -A ) 0## 0 A
; 3GO2III


#$ G8 G/%"; ("."8=D
%/-=G; A0
) #$$N*!5<6A77L7<<


#2 /' = 8 %4 A E
NOP #0
! ! #$$N*5<6A<7#<7I


## G %/A 3 . "/ + 3
) 3 #$$L


#* . GA" +0 +
+ ( $ (#$2#


#7 ""=/A##/$ A;1;
O#$$N


#< /(!8('A A/',;O2IIL
#K ! '/A$ 0Q2P 0 2III1,A#$$7
#N / 8G ' 8C /.;A


)/ 9 +) #$$N%A*$
#L %8A 0'A


" D ! 7GG;!C"; A#L##LK
#I %./4A(G + A!C"; O2III
*$ C %A 0 $ G # D


2IK<&576A7*K77<
*2 =%"! 4=A #2II#
*# 3 GA # 0 'A ) )


) D@ +' ' >D!! /2II7
** % ; A ( * '#A


;!)!O#$$<
*7 F G G,8 ; >4 ;-4 =,A #


0 # 0 +
#$$*1'A#**$


*< 3 G/8A 'A !)
)PGA ) 7GGA@ D' ,!' 7: !! /A#7I#<K


*K . ! -A ( < # (
. 00# # )
50D$ ((>D 1 !' D D'
1 #$22


*N -8 G ( " % G; 3 ,A $
) #/ ? " . #@ 00
##0 ) 0 N #$$#&-5<6A#7L#KN#$I


*L $ ) # 7$)8/ 0 < )
)P A111 1./"!Q


*I .$ $ ) # P A11
1 Q


7$ 0/ $ ) #
7$)8P A111(1 1 1Q




#7N


72 &,* 0 . (( , 'A G
O#$2*


7# +E 5 D &,& '# #$2* A !
O#$2#


7* >3 ;A $ ) #'#
#$2*A> ! 3 ; O#$$2


77 GA . ) ) ! %
+ D #$22A"2 "2L


7< &G%( %.- /8A. 0#
/ 0 ) 0
N D #$2$1'576A2<#


7K /8A; (/L ) D
N #$$I5 1 #$$I6AKN


7N !A$ /+0 #$$$1&,5N#*N6AN#KN#N
7L !;,,A$ /(NOR 00#


! #$2$!5*6A#*#N
7I /A M M #/


0 0 ) N #$2#&%526A2<
<$ + # S L



P A11+ 1.(T T TT8 T T!
TT! T;1Q


<2 + # = ? " . #
P A11 11Q


<# .$ =+ #P A111 Q
<* #


P A11 1"1 81' !1-
1 R#$' R#$!R#$.(;-.Q


<7 . # = + # S
P A11(11 1Q


<< /%(=% GA(/<
. #!; A.8
' 5>7A;,; 68(/-O#$$<


<K / 8 C > !A 00 ;
0 #/$ # 0 #$2$526A<#
<N


<N / -!A # M ; M/ 0
2A, ) O#$$2


<L -C,AC .$+ # C ;
$ 2IL2%,5226A*<*K


<I " 8'A ) ) 1
2II*&&5LI6A#


K$ " 8'A). +) .0 1
2ILN'526A#




#7L


K2 - /A #.<03)5 #'A)
#2II*


K# ")'A$ 4 #2II*
K* "/ -. ! G C =; -( 8A#0


E 0D0# 0 !
! #$$K15<6A<7N<<K


K7 !A 5)0 0
#$$<F5*6AN2NL


K< A =. ( 0 'A ,
##$$<


KK .-!A >$T )2 0
>$'#" -88(O#$2<


KN .-!A< # ( . =
> #/ 0 = " A!,7 8B
.=( < '#" -88(O#$2$


KL G,8FG; >4=!,X%GG;-,G;A
0 # 0 0 '#A -,' - O
#$$<


KI !4A 00# 0
/ # 'A
" D ! 8AA;!C"; A2L2<2L2I


N$ ;B ! && G! ! " ! A . $
/ $ 0
+ K #$2$**526A7I<K


N2 CCA /
0 0 = 0 + #$$<
1-5*6A#2*#2I


N# 3; '!4!A00# 0 # 00
9 9 E 00 0
+ " #$2215#6AI*IL


N* ' ! !/A".:$)%!/ &,,F/ /
( !!' ! #$$I


N7 '( "A 5 $ (
. 'A D " )
+ 5 787F 8A78 8A78#$2<


N< 8G=%,A#0 $/0
0 + #$2$*1526A2<I2N#


NK 4 48A #
0 N #$$<A7K27I2


NN /(/4A909 $.0 ) !)
2IL*&'5K6A7*$777


NL F A / 0A
; O2ILL


NI 4& 3/ 8 8,A$ / 0 ! !
#$$$%5#6A22K2#7




#7I


L$ /G ;A " #9 9 D /
. 0 0 # 0
0 2II<!526AII22K


L2 4\] " C . !A(@
#0 / #+0 #$$21&15N*#<6A2*772*7L


L# -.-A90 9 0
# N 2ILIA*2I*7$


L* -.-%&&8;;8A 0 0#/
0 D 2ILI 1!5L6AIL#
2$$*


L7 > =G=%(=C !%!A
0 = / 0
0 #) 0 ! #$$*!,576A*#L**#


L< /% ; ( ( /" ;A 0
0 2IIL&-,52N6A27L7


LK 0 = 00 0
0 1 2IIN&'5I
2$6A*LI*I2


LN )/ =0'A
D D !##$2*;!A' /
; O2III


LL 44'8-&=(> =--GA00#
( $ )E0/ = 0
) ) 2IIL*576A#<*#K*


LI .(8G A ( > #
$ ) 0 ) 0 N D
#$$71,52$6A<NI<L7


I$ C 8 4 G 4 ! G - G GA =
) 0
" D ! #$$7*-52<6A2NN*2NNN


I2 = 8 GA$ ( =. #/ 0
)+ $ #$$$


I# " / 4 DA /
+ / < ! = #$2$F5<6A*$$*$<


I* 3A . /$ '#O#$2<
I7 + # +0 '# #$27 , A


' / ; O#$$N
I< .-88M=!!, / % !A


/ 0 #
D ? !' '
#$27 15#6A227K





#7L


002/ # ##
/ (


'


,

(
(
3


%
5 6 ;
!
1 ,
PI<QA


• 1+ O



5 6O


• ( O


• &( O


• 1+ 5
( 6O


!


,


( '


' +

& (




#7I


( (

C(
A






(
,
!8" ' " ,
A11 111*$LK*1KK##*7 2<N$#I$N$L
N#* & M


!
(.(
AC PI<Q!
(
A


A111112$##$$1$$K$K"-2>$#D#$272$!8$$N1
T 1.T 2





. 0


3"3,,;!8,' ';!,"'3!)!%'4',D,)-D




You are being asked to take part in a usability study. Please read this explanation about the study and its
risks and benefits before you decide if you would like to take part. You should take as much time as you
need to make your decision. You should ask the study staff to explain anything that you do not
understand and make sure that all of your questions have been answered before signing this consent
form. Before you make your decision, feel free to talk about this study with anyone you wish. Participation
in this study is voluntary.


0


The purpose of this project is to [insert purpose here]. Your participation helps us to determine [insert
benefit here such as “identify which product is the safest for your unit”].




If you agree to participate in the study your demographic information (e.g., age, sex, years nursing
experience) will be collected and you will be asked to complete a series of clinical tasks in a simulated
clinical environment. In other words, you will be in a room with clinical equipment and scenarios but no
real patients or patient care. You will be taught how to use the devices not in routine use on your unit prior
to starting the simulations. After training you will be oriented to the simulated environment, and asked to
perform various tasks to a simulated patient (mannequin and/or actor). After each scenario, we will ask
you for your feedback based on our observations to further understand the risks and benefits of the
devices being tested. The session will last no more than 3 hours, and will be videotaped for later analysis.
Your performance/competency is NOT being evaluated in a way that will impact your employment, but
rather the results of this study will be used to better understand issues relating to the devices we are
evaluating.


+


There are no anticipated or known medical risks associated with this study. You may experience
discomfort in sharing your opinions with the researchers. You only have to share as much about your
opinions as you wish. Your participation will have NO impact on your employment.




You may or may not receive direct benefit from participating in this study. Information from this study may
help to increase your knowledge about [insert the type of device here].


? # 0


Your participation in this study is voluntary. You can choose not to participate or you may withdraw at
any time. Whether you choose to participate or not has no impact on your employment. In no way does
signing this consent form waive your legal rights nor does it relieve the investigators, sponsors or involved




institutions from their legal and professional responsibilities. You do not give up any of your legal rights by
signing this consent form.


#


All information obtained during the study will be held in strict confidence. You will be identified with a
subject number only. No names or identifying information will be used in any reports, publication or
presentations that may come from this study. No information identifying you will be transferred outside
the investigators of this study. If the videos from the research are shown outside the research team, your
face will be blurred and all identifying information will be made anonymous. However, despite best
efforts, there is a very small possibility that you may still be identified. Data from the study (e.g.,
videotapes, paper records) will be kept for a minimum of two years, and a maximum of seven years, after
the completion of the study. Any personal identifiable information will be stored and protected on secured
servers or kept in a locked filing cabinet and then destroyed by shredding of paper or erasing of digital
information.


+


You will not receive any financial reimbursement for your participation.


G


If you have any questions, concerns or would like to speak to the study team for any reason, please
contact [insert contact name and information of person responsible for the study.




This study has been explained to me and any questions I had have been answered. I know that I may
leave the study at any time. I agree to take part in this study.






Study participant’s name (please print) Participant’s Signature Date
(You will be given a signed copy of this consent form)


My signature means that I have explained the study to the participant named above. I have answered all
questions.






Name of person obtaining consent Signature Date







#<#





=U9$.9)
! '
" ) , #$$#


!M (



^
A11(11




9(
; 8 4 " , )
3 ( ! ; ' %
%" ' -
;/ " . /)
,



^
A11(11





$ <9$.9)
/
/ " )
, (


( (


/ ^
A11(11 7











#<*


J>J9$)9(

D4 % / -
/C ) )
,




^


A11(11





#7#8) #9(9)9)
, ' %
, ) 3 (1)
, ' %
% -" M


", ;-/



^
A11(11











Copyright 2016, Engineering World Health