Media Relations Permission Form [EXAMPLE] Title of Research Study: [insert title of research study here with protocol number, if applicable] Investigator: [insert name of principal investigator] Supported By: [List all monetary and/or non-monetary support for this research. If none, state, e.g., Northwestern University, Shirley Ryan AbilityLab, Northwestern Memorial Hospital, etc.] Introduction/Purpose: As a participant in the above study, we are asking if you would agree to be interviewed by a media professional for a segment or article to be published either on TV, radio, newspapers, magazine or online. The purpose of this interview is to help bring awareness and education to the public about this research [state what the research is studying]. Procedures: If you give your permission, the media relations team will coordinate with the media professional to schedule an interview for you at a place and time that are convenient for you. The interview will take place at Northwestern Memorial Hospital, your home or another location that you prefer. The media professional will record (video and audio) and take notes during the interview. You will be asked questions about your participation in this research and your health condition. Your care provider will also be interviewed about your participation in the trial. The taped interview may air on television, radio or online. Your statements will be attributed to you and you will be identified in any media stories that result from the interview. Your participation is completely voluntary. If you agree or do not agree to participate, it will not affect your participation in the main research study in any way. If you agree to participate, you do not have to answer any questions that you do not want to answer. The following things about agreeing to be interviewed by a media professional are important for you to understand: It is very important to remember that the study data is still being collected and/or analyzed, and that statements claiming efficacy of the treatment should be avoided. The decision to give your permission is entirely up to you. You can refuse to give your permission. If you refuse, it will not affect your current or future participation in the Your decision will not affect any health care or correctional Northwestern Project. services or benefits.
Media Relations Permission Form [EXAMPLE] Title of Research Study: [insert title of research study here with protocol number, if applicable] Investigator: [insert name of principal investigator] Supported By: [List all monetary and/or non-monetary support for this research. If none, state, e.g., Northwestern University, Shirley Ryan AbilityLab, Northwestern Memorial Hospital, etc.] Introduction/Purpose: As a participant in the above study, we are asking if you would agree to be interviewed by a media professional for a segment or article to be published either on TV, radio, newspapers, magazine or online. The purpose of this interview is to help bring awareness and education to the public about this research [state what the research is studying]. Procedures: If you give your permission, the media relations team will coordinate with the media professional to schedule an interview for you at a place and time that are convenient for you. The interview will take place at Northwestern Memorial Hospital, your home or another location that you prefer. The media professional will record (video and audio) and take notes during the interview. You will be asked questions about your participation in this research and your health condition. Your care provider will also be interviewed about your participation in the trial. The taped interview may air on television, radio or online. Your statements will be attributed to you and you will be identified in any media stories that result from the interview. Your participation is completely voluntary. If you agree or do not agree to participate, it will not affect your participation in the main research study in any way. If you agree to participate, you do not have to answer any questions that you do not want to answer. The following things about agreeing to be interviewed by a media professional are important for you to understand: It is very important to remember that the study data is still being collected and/or analyzed, and that statements claiming efficacy of the treatment should be avoided. The decision to give your permission is entirely up to you. You can refuse to give your permission. If you refuse, it will not affect your current or future participation in the Northwestern Project. Your decision will not affect any health care or correctional services or benefits.
4-18-18_Media%20Permission%20Form-Example.docx