Sample Research Registry Informed Consent Form (Page 2 of 5) in pdf

University of Pittsburgh

Institutional Review Board

IRB #:

Approval Date: ___/____/_____

Renewal Date: ___/____/_____

evaluating the safety and effectiveness of drugs, devices or procedures for the treatment of XX

disease. If you agree to participate in this Research Registry, your medical record information

will be reviewed by physicians and researchers to determine if you might qualify for various

future research studies.

Who is being asked to participate in this Research Registry?

All adult patients who are seeking treatment or are being treated at the UPMC Center for XX

Disease are being asked to participate in this Research Registry.

What will my participation in this Research Registry involve?

If you agree to participate in the Center for XX Disease Research Registry your past, current and

future medical record information will be placed into the Research Registry. This will permit

research studies to be conducted on the medical record information contained within the registry.

You are being asked to allow us to contact you if one of our researchers determines, through

review of your medical record information contained in the Research Registry, that you are

eligible for participation in a future research study directed at the study of XX disease. Please

note that if you qualify for any future research studies, you will be asked to sign a separate

consent form that outlines in detail the nature of this research study, including its potential risks

and benefits.

What are the possible risks of my participation in the Research Registry?

There are no risks of physical injury associated with your participation in the Center for XX

Disease Research Registry. Participation in this Research Registry does involve the possible risk

that information about your health might become known to individuals outside of the Center for

XX Disease.

We will attempt to preserve your medical record confidentiality by assigning a special research

code number to your medical record information stored in the Research Registry, and by

removing personal identifiers (for example, your name, social security number, medical record

number) from information stored about you in the Research Registry. Information linking the

research code number to your name and other personal identifiers will be stored in a separate

secure location. Access to any identifiable information about you that is contained within the

Research Registry will be limited to investigators associated with the Center for XX Disease and

their research staffs.

What are the possible benefits of my participation in the Research Registry?

Participant’s Initials _____

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Sample Research Registry Informed Consent Form Page 2