Participant Registry: Consent Form

University of Washington

VTEU Participant Registry

Consent Form

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Thank you for your interest. This registry is meant for individuals 18 years of age or older.

eConsent Date

M-D-Y

Eletronic Consent Statement

UW VTEU General Screening Protocol

Reseacher(s)		Phone Number
Anna Wald, MD, MPH	Professor, Medicine	(206) 520-4340

Thank you for your interest in the UW VTEU. We are asking you to be in a research registry.

The purpose of this registry is to see whether you are eligible for vaccine or treatment studies at our clinic. We will ask you demographic questions as well as a a series of personal medical questions about your health and medications. This may take 10-20 minutes. You do not have to answer any questions that you do not want to answer, and you may stop at any time. Based on the answers to our screening questions, you may be eligible for a current study, or you may be eligible for a study in the future.

Your answers to our questions will be recorded and kept in a secure database. All information will be kept confidential. Only the study team will have access to this information; it will not be shared with other research groups. The personal medical information you provide will be kept separate from your name.

Our research team will keep your information and data indefinitely.

You will not benefit directly from taking part in the registry. Possible risks of participating in the registry include breaches of confidentiality.

Your participation in this registry is voluntary. You may refuse to participate and you are free to withdraw from the registry at any time without penalty or loss of benefits to which you are otherwise entitled. Withdrawing will not affect your participation in other studies or your care at our clinic. IIf you decide at a later time that you do not want your information stored in our registry, please notify our clinic staff by calling 206-520-4340 and we will destroy your data.

If you have questions about your rights as a research subject, you can call the University of Washington Human Subjects Division at (206) 543-0098 or call collect at (206) 221-5940.

Do you consent to be added to our registry for future research studies?

If you would like to participate without being added to our registry, please give our clinic a call at 206-520-4340. You may now close this tab.

Would you like to be provided with a written statement about the registry?

Yes

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How would you like to receive the written statement?

Download the statement now

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The registry statement is available here to download

Attachment:

Registry Information Statement_24NOV21.pdf

Name:
Date:

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