10.1 Who can I contact about this study? Please contact the researchers listed to: Obtain more information about the study Ask a question about the study procedures or treatments Talk about study-related costs to you or your health plan Report an illness, injury, or other problem (you may also need to tell your regular doctors) Leave the study before it is finished Express a concern about the study Principal Investigator: Mailing Address: Telephone: Study Coordinator: Mailing Address: Telephone: You may also express a question or concern about a study by contacting the Institutional Review Board listed below: University of Michigan Medical School Institutional Review Board (IRBMED) 2800 Plymouth Road Building 520, Room 3214 Ann Arbor, MI 48109-2800 Telephone: 734-763-4768 (For International Studies, include the appropriate .) Fax: 734-763-1234 e-mail: If you are concerned about a possible violation of your privacy or concerned about a study you may contact the University of Michigan Health System Compliance Help Line at 1-866-990-0111. When you call or write about a concern, please provide as much information as possible, including the name of the researcher, the IRBMED number (at the top of this form), and details about the problem. This will help University officials to look into your concern. When reporting a concern, you do not have to give your name unless you want to. 11. record of Information provided 11.1 What documents will be given to me? Your signature in the next section that you have received copies of all of the following documents: This "Consent to be Part of a Research document. (Note: In addition to the copy you receive, copies of this document will be stored in a separate confidential research file and may be entered into your regular University of Michigan medical record.)
10.1 Who can I contact about this study? Please contact the researchers listed to: Obtain more information about the study Ask a question about the study procedures or treatments Talk about study-related costs to you or your health plan Report an illness, injury, or other problem (you may also need to tell your regular doctors) Leave the study before it is finished Express a concern about the study Principal Investigator: Mailing Address: Telephone: Study Coordinator: Mailing Address: Telephone: You may also express a question or concern about a study by contacting the Institutional Review Board listed below: University of Michigan Medical School Institutional Review Board (IRBMED) 2800 Plymouth Road Building 520, Room 3214 Ann Arbor, MI 48109-2800 Telephone: 734-763-4768 (For International Studies, include the appropriate .) Fax: 734-763-1234 e-mail: If you are concerned about a possible violation of your privacy or concerned about a study you may contact the University of Michigan Health System Compliance Help Line at 1-866-990-0111. When you call or write about a concern, please provide as much information as possible, including the name of the researcher, the IRBMED number (at the top of this form), and details about the problem. This will help University officials to look into your concern. When reporting a concern, you do not have to give your name unless you want to. 11. record of Information provided 11.1 What documents will be given to me? Your signature in the next section that you have received copies of all of the following documents: This "Consent to be Part of a Research document. (Note: In addition to the copy you receive, copies of this document will be stored in a separate confidential research file and may be entered into your regular University of Michigan medical record.)
res_irbmed_20180309--workingStandardConsentTemplate_1.docx