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1、IRBUseOnlyApprovalDate:Monthnamedd,20yyExpirationDate:Monthnamedd,20yySTANFORDUNIVERSITYResearchConsentFormProtocolDirector:ProtocolTitle:SAMPLECONSENTFORMForProspectiveCollectionofMedicalInformation/DataDESCRIPTION:Youareinvitedtoparticipateinaresearchstudyondiabetes.
2、Fromtheinformationcollectedandstudiedinthisprojectwehopetolearnmoreaboutdiabetes,includingfactorsthatmayaffectthedevelopmentandprogressionofthiscondition.PROCEDURES:Withyourpermission,wewouldliketocollecthealthinformationaboutyou,includinginformationaboutyourgeneralhea
3、lth(height,weight,bloodpressure,resultsfrombloodtests,medications,physicalexamresults)relatedtomedicaltreatmentsandcareyoureceive.WewouldliketocollectthisinformationaboutyouaftereachmedicalvisityouhaveforaslongasyouaretreatedataStanfordClinicorhospital.Thisstudydoesnot
4、involveanytreatment;justthecollectionandstudyofmedicalinformation.RISKSANDBENEFITS:Therearenoanticipatedrisksassociatedwiththisstudy.Youwillnotreceiveanydirectbenefitfromparticipation.Wecannotanddonotguaranteeorpromisethatyouwillreceiveanybenefitsfromthisstudy.TIMEINVO
5、LVEMENT:Yourparticipationinthisstudywillnotrequiremoretimefromyouotherthanfortheinitialvisitwherethisstudyisexplainedtoyou.Ifyouagreetoparticipate,wewillcollectyourmedicalinformationfromyourmedicalrecordaftereachvisit,whichdoesnotinvolveanydirectparticipationbyyou.PAYM
6、ENTS:Youwillnotbepaidtoparticipateinthisstudy.PARTICIPANT’SRIGHTS:Ifyouhavereadthisformandhavedecidedtoparticipateinthisproject,pleaseunderstandyourparticipationisvoluntaryandyouhavetherighttowithdrawyourconsentordiscontinueparticipationatanytimewithoutpenaltyorlossofb
7、enefitstowhichyouareotherwiseentitled.Theresultsofthisresearchstudymaybepresentedatscientificorprofessionalmeetingsorpublishedinscientificjournals.However,youridentitywillnotbedisclosed.Ifapplicable:Youhavetherighttorefusetoanswerparticularquestions.Form:SUSampCons-dcr
8、ev06/124of4IRBUseOnlyApprovalDate:Monthnamedd,20yyExpirationDate:Monthnamedd,20yySTANFORDUNIVERSITYResearchConsentFor
