ࡱ> _ Ubjbjzyzy Fa6b6b!!!!!&!&!&!8^!d!&!^""L,#,#,#`$`$`$ޝ$oQ!`$`$`$`$`$!!,#,#4U6(6(6(`$^!,#!,#,6(`$ޝ6(6(b$,#0]IT$Vk06L%!`$`$6(`$`$`$`$`$&H`$`$`$`$`$`$`$`$`$`$`$`$`$`$`$`$B : Consent to Participate in Research (Short ForM)TITLE OF RESEARCH STUDY:  FORMTEXT       Principal Investigator: FORMTEXT       Department:  FORMTEXT       Introduction: This form provides an outline of some key information about a research study followed by the required elements of informed consent. Key Information: A researcher will present a summary of the key information to assist you in understanding the reasons why one might or might not want to participate in the research. If you are interested in learning more about the study, the informed consent process will continue. You may discuss this information with the researcher. Permission to Participate in a Research Study: We are asking your permission to participate in a research study. If you are providing permission for someone else to participate in the research, as his or her Surrogate, Legally Authorized Representative, Parent, or Legal Guardian, the terms you and your refer to you and the research participant. Basic Information: We are presenting the following information orally to you in your preferred language: the purpose of the research, the expected duration of your participation in the research, the procedures that will be followed, any procedures which are experimental, any reasonably foreseeable risks, discomforts, or benefits, whether there are any potential beneficial alternative procedures or treatments, how your privacy and confidentiality will be protected and who will see your information, and whether identifiers might be removed from your information or specimens to be used for future research without obtaining additional informed consent or whether your information or specimens will not be used or distributed for future research. Your participation in this research is voluntary, and you will not be penalized or lose benefits if you refuse to participate or decide to stop. However, any information collected about you prior to withdrawal must remain in the records, when required by the government regulations or approved by an Institutional Review Board. Additional Information: Where applicable, the investigator must also tell you about: any available compensation or medical treatment if injury occurs the possibility of unforeseeable risks to you or to your child, if you are pregnant or become pregnant, circumstances when the investigator may stop your participation, any added costs to you, what happens if you decide to stop participating, when you will be told about new findings which may affect your willingness to participate, how many people will be in the study, any genetic testing that may take place, whether clinically relevant research results will be returned to you and, if so, under what conditions, whether it is ok to contact you in the future to seek additional information or specimens or to discuss participation in another research study, the types of specimens or information that will be collected and the time period for which they will used for research, whether specimens (even if identifiers are removed) may be used for commercial profit and if so, whether research participants will share in this commercial profit, whether and under what conditions any clinically relevant research results will be shared with you, or, whether we will (if known) or might do whole genome sequencing. questions about:May be directed to:The research Research related injury How to withdraw from the studyName:  FORMTEXT       Telephone: ( FORMTEXT      ) FORMTEXT      - FORMTEXT       Page Operator: (718) 270-1000Your rights Privacy rights How to withdraw from the study You may contact the person(s) listed above or call Institutional Review Board: (718) 613-8480 Hospital Privacy Officer: (718) 270-7470 SIGNATURES: Research Participant, Surrogate, Legally Authorized Representative, Parent, or Legal Guardian: I have read this form and all of my questions about this research have been answered to my satisfaction. I volunteer to participate in this research study. 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