Close relative or friend (initials) Who may you contact if you have any additional questions? Only use the number(s) for the location(s) where the research is being done. Always include the IRB number. questions about: May be directed to: The research ENTER NAME(S) Research related injury Telephone: (718) XXX-XXXX How to withdraw from a study Pager: (718) XXX-XXXX ENTER NAME(S) Telephone: (718) XXX-XXXX Pager: (718) XXX-XXXX Your rights Institutional Review Board: (718) 613-8480 Privacy rights Hospital Privacy Officer: (718) 270-4033 How to withdraw from a study Concerns to be directed to an institutional representative who is not part of this research study Interpreter or translation services Patient Relations Department: (718) CONTACT INFORMATION: Before signing this form, please provide your contact information: Address: Telephone: ______________________________ ___________________ ______________________________ (daytime) ______________________________ ___________________ ______________________________ (evening) **Email Address (optional): __________________________ ** Your e-mail address will not be used for insecure communications of protected health care information. Signatures Instructions: Use only the required boxes based on the research and delete all others. Minor edits to the language may be needed, depending on the exact nature of the study.
Close relative or friend (initials) Who may you contact if you have any additional questions? Only use the number(s) for the location(s) where the research is being done. Always include the IRB number. questions about: May be directed to: The research Research related injury How to withdraw from a study ENTER NAME(S) Telephone: (718) XXX-XXXX Pager: (718) XXX-XXXX ENTER NAME(S) Telephone: (718) XXX-XXXX Pager: (718) XXX-XXXX Your rights Privacy rights How to withdraw from a study Concerns to be directed to an institutional representative who is not part of this research study Institutional Review Board: (718) 613-8480 Hospital Privacy Officer: (718) 270-4033 Interpreter or translation services Patient Relations Department: (718) CONTACT INFORMATION: Before signing this form, please provide your contact information: Address: ______________________________ ______________________________ ______________________________ ______________________________ Telephone: ___________________ (daytime) ___________________ (evening) **Email Address (optional): __________________________ ** Your e-mail address will not be used for insecure communications of protected health care information. Signatures Instructions: Use only the required boxes based on the research and delete all others. Minor edits to the language may be needed, depending on the exact nature of the study.
TEMPLATEConsent-Guidance01.06.2017.docx