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

University of Pittsburgh

Institutional Review Board

IRB #:

Approval Date: ___/____/_____

Renewal Date: ___/____/_____

medical record information prior to the date that you formally withdraw your permission will not

be destroyed.

To formally withdraw your permission for participation in the Center for XX Disease Research

Registry you should provide a written and dated notice of this decision to the principal

investigator of the Research Registry at the address listed on the first page of this consent form.

*****************************************************************************

VOLUNTARY CONSENT

All of the above has been explained to me and all of my current questions have been answered. I

understand that I am encouraged to ask questions about any aspect of my participation in the

Research Registry at any time, and that such future questions will be answered by the physicians

associated with the Center for XX Disease or their research staffs. I understand that a copy of

this consent form will be given to me.

I understand that any questions which I have about my rights as a participant in the Research

Registry will be answered by the Human Subject Protections Advocate of the IRB Office,

University of Pittsburgh (1-866-212-2668).

By signing below, I agree to participate in the Center for XX Disease Research Registry.

___________________________________

________________

Participant’s Signature

Date

CERTIFICATION OF INFORMED CONSENT

I certify that I have explained the nature and purpose of the Center for XX Disease Research

Registry to the above-named individual, and I have discussed the possible risks and potential

benefits of participation in this Research Registry. Any questions the individual has about this

Research Registry have been answered, and the physicians and research staff associated with the

Center for XX Disease will be available to address future questions as they arise.

___________________________________

Printed Name of Person Obtaining Consent

___________________________________

___________________

Signature of Person Obtaining Consent

Date

Participant’s Initials _____

Page 5 of 5

Sample Research Registry Informed Consent Form Page 5