ࡱ>  LbjbjSS FW11PPPPPddd8Td# !LR!R!R!"""rtttttt$AEP"""""PPR!R!4ݚ%%%"PR!PR!F,%"r%%b$̏R!0VLad#vȉV20##f̏̏PP""%"""""$("""#""""""""""""" : Consent to Participate in Research (Short ForM)TITLE OF RESEARCH STUDY:  FORMTEXT       Principal Investigator: FORMTEXT       Department:  FORMTEXT       You are being asked to participate in a research study. If you are providing permission for someone else to participate in the research, as their Legally Authorized Personal Representative, Parent, or Legal Guardian, the terms you and your refer to you and the research participant. The following information shall be orally presented 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, and how your privacy and confidentiality will be protected and who will see your information. 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. 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, or the types of specimens or information that will be collected and the time period for which they will used for research. questions about:May be directed to:The research Research related injury How to withdraw from the study 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, Legally Authorized Personal Representative, Parent, or Legal Guardian: I have read this form and all of my questions about the research have been answered to my satisfaction. The research has been explained to me orally. By signing, I acknowledge that I have received and understand all of the information listed above and voluntarily agree to participate in this research study. If signing as the Legally Authorized Personal Representative, I authorized the research based on my understanding of the wishes of the research participant.  _____________________________ Print Name ______________________________ Signature  ______________ Date Signed Interpreter  _____________________________ Print Name ______________________________ Signature ______________ Date Signed Impartial Witness  _____________________________ Print Name ______________________________ Signature  ______________ Date Signed Investigator Obtaining Informed Consent _____________________________ Print Name ______________________________ Signature  ______________ Date Signed DISTRIBUTION: SIGNED ORIGINAL: INVESTIGATOR'S RESEARCH FILE. COPY: PERSON AUTHORIZING THE RESEARCH. 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