Sample Research Registry Informed Consent Form (Page 4 of 5) in pdf

University of Pittsburgh

Institutional Review Board

IRB #:

Approval Date: ___/____/_____

Renewal Date: ___/____/_____

staffs. A current, complete listing of these individuals will be provided to you upon your written

request.

In addition, the following individuals may have access to your identifiable medical record

information contained within this Research Registry:

Authorized representatives of the University of Pittsburgh Research Conduct and Compliance

Office may review information contained within the Center for XX Disease Research Registry to

ensure that the Research Registry adequately protects your privacy.

In unusual cases, the researchers may be required to release your identifiable medical record

information from the Research Registry in response to an order from a court of law.

For how long will my medical record information continue to be placed in the Research

Registry and for how long will this information be used for research purposes?

We will continue to place your medical record information into the Center for XX Disease

Research Registry until 1) you are no longer living; or 2) you withdraw your permission for

participation in the Research Registry.

Your medical record information contained within the Center for XX Disease Research Registry

will be used for research purposes for an indefinite period of time.

Is my participation in the Research Registry voluntary?

Your participation in the Center for XX Disease Research Registry, to include the use of your

medical record information for the research purposes described above, is completely voluntary.

Whether or not you provide your permission for participation in this Research Registry will have

no affect on your current or future medical care at the University of Pittsburgh Medical Center,

affiliated health care provider, or your current or future relationship with a health care insurance

provider. Whether or not you provide your permission for participation in this Research Registry

will have no affect on your current or future relationship with the University of Pittsburgh.

May I withdraw, at a future date, my consent for participation in this Research Registry?

You may withdraw, at any time, your consent for participation in the Center for XX Disease

Research Registry, to include the additional collection of your medical record information and its

further use for the research purposes described above. However, any research use of your

Participant’s Initials _____

Page 4 of 5

Sample Research Registry Informed Consent Form Page 4