Millikin University Irb Consent Form Instructions (Page 6 of 7) in pdf

Sample 2

Sleep Apnea & Heart Failure Project Consent

I understand that I have been invited to participate in a research study at the Heart

Institute - Heart Failure Clinic that is enrolling approximately 200 current patients. This

study will evaluate the effectiveness of education provided on sleep apnea, heart failure,

and continuous positive airway pressure therapy.

I agree to participate in this study by providing answers to questions about my feelings

and expectations regarding the use of a continuous positive airway pressure machine

(CPAP). The survey takes 30 minutes or less to complete. The survey must be completed

at the Heart Institute - Heart Failure Clinic before or after your clinic visit, or by scheduling

an appointment (call 333-333-3333 for an appointment). I understand that my

participation in this study is completely voluntary, and has no impact on the care and

treatment I receive from the Heart Institute - Heart Failure Clinic. I understand that I can

refuse to answer any question or end my participation at any time without any penalty.

I understand that my responses are anonymous and that no identifying information will

be linked to my survey responses. The responses I provide will only be reported as

aggregated or group data, and only used for educational and/or scientific purposes. I

understand that the information gained from the study will help provide insight to the

understanding CPAP barriers and compliance and will help inform those providing

education and treatment to better help others with sleep apnea and heart problems.

There are no known risks associated with participating in this study, and I understand

that if injury from the research study occurs, I will not automatically be compensated by

the Heart Institute. I understand that none of my legal rights regarding negligence and

the liability of Millikin University or its agents have been waived. I understand that if I

have any questions regarding the study, I can contact the lead researcher at Dr. XXX at

222-222-222 or via email at . If I have any questions about my rights as a

subject, I may contact Dr. XXXX, Millikin University IRB Chair at xxx-xxx-xxxx or via email

at x@millikin.edu. I understand that I will be given a copy of this consent form to keep for

later reference.

I understand that sealing my survey answer sheet in envelope provided and placing it

in the survey return box demonstrates my consent to participate.

Participant’s Signature: _______________________ ______ Date: __________________

Printed Name: ____________________________

_____ Date: __________________

IRB Consent Form Guidelines

2/13/2015

Millikin University Irb Consent Form Instructions Page 6