Sample Research Registry Informed Consent Form

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University of Pittsburgh
Institutional Review Board
IRB #:
Approval Date: ___/____/_____
Renewal Date: ___/____/_____
SAMPLE RESEARCH REGISTRY
INFORMED CONSENT DOCUMENT(3.03)
(Division, Department, School or Center Letterhead)
CONSENT TO ACT AS A PARTICIPANT IN A RESEARCH REGISTRY
TITLE:
UPMC Center for XX Disease Research Registry
PRINCIPAL INVESTIGATOR:
CO-INVESTIGATORS:
UPMC Center for XX Disease Physicians and Research Staff
(Complete, current listing available upon request)
SOURCE OF SUPPORT: UPMC Center for XX Disease
What is the purpose of this Research Registry?
Many advancements in medicine have resulted from research involving the collection and
analysis of the medical record information of patients with a certain disease or condition.
Because you are being seen by the UPMC Center for XX Disease, we are asking for your
permission to allow us to place your past, current and future medical record information into a
Center for XX Disease Research Registry. By placing the medical record information of many
patients such as you into a research registry, researchers will be able to conduct research studies
directed at increasing our knowledge about XX disease.
It is anticipated that the Research Registry will assist our investigators in two important ways.
First, it will allow researchers to review and study the medical records of many individuals to
answer questions about your disease and its treatment.
Second, it will help researchers identify and recruit patients who are eligible for participation in
future research studies. For example, physicians and other researchers associated with the
UPMC Center for XX Disease are also frequently involved in research studies directed at
Participant’s Initials _____
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