Volunteer Consent Survey

This is a repository, a type of research database.

You are eligible to join this repository if you are between the ages of 18-89 and do not have a serious medical condition that would interfere with your ability to give informed consent or participate in repository activities.

Old registrant

Registrant enrolled before 3/6/2017

INFORMATION SHEET

IRB: 10709

PRINCIPAL INVESTIGATOR: Rupali Avasare, MD (503) 494 3442

REPOSITORY GUARDIAN: Celena Byerlee-Dixon, MS (971) 334-1942

PURPOSE:This is a repository, a type of research database. The purpose of this repository is to create and maintain a list of healthy adults who are interested in participating in future research studies, and are willing to provide health information and biological specimens such as blood, urine, saliva and stool for research. This research registry is not intended to be contacted for a specific study. For assistance to locate or be contacted for a specific study, please email octrirecruitment@ohsu.edu.

PROCEDURES:If you are eligible for a future research study, you will be invited to come to OHSU for a study visit, which may take up to 1 hour. There is no limit to the number of studies/visits you can agree to participate in, and your repository participation will last indefinitely. Participation in future studies is voluntary and you do not have to agree to participate in a study to continue participating in the repository.You will sign a separate consent form for future research studies. Studies can be for any medical condition and may include genetic research. Genes are the units of DNA- the clinical structure carrying your genetic information - that determine many human characteristics such as the color of your eyes, your height, and whether or not you are male or female.If you have any questions, concerns, or complaints regarding this study now or in the future, or you think you may have been injured or harmed by the study, contact Rupali Avasare, MD or Celena Byerlee-Dixon at (971) 334-1942.

RISKS:Although we have made every effort to protect your identity, there is a minimal risk of loss of confidentiality. Any additional risks for future research will be listed in the information sheet or consent form.

BENEFITS:You may or may not benefit from being in this study. However, by serving as a subject, you may help us learn how to benefit patients in the future.

CONFIDENTIALITY:We will take steps to keep your personal information confidential, but we cannot guarantee total privacy. We may request your social security number in order to process any payments for participation.

COSTS:You will be compensated $30 for your screening visit to OHSU. If you are asked to provide a stool sample, you will be compensated an additional $10.00. Future studies may provide additional compensation. This information will be provided in a separate consent or information sheet.

PARTICIPATION:This research is being overseen by an Institutional Review Board ("IRB"). You may talk to the IRB at (503) 494-7887 or irb@ohsu.edu if:
- Your questions, concerns, or complaints are not being answered by the research team.
- You want to talk to someone besides the research team.
- You have questions about your rights as a research subject.
- You want to get more information or provide input about this research.You may also submit a report to the OHSU Integrity Hotline online at https://secure.ethicspoint.com/domain/media/en/gui/18915/index.html or by calling toll-free (877) 733-8313 (anonymous and available 24 hours a day, 7 days a week).Your participation in this study is voluntary. You do not have to join this or any research study. If you do join, and later change your mind, you may quit at any time. If you refuse to join or withdraw early from the study, there will be no penalty or loss of any benefits to which you are otherwise entitled.If you no longer want your health information to be used and disclosed as described in this form, you must send a written request or email stating that you are revoking your authorization to:
Celena Byerlee-Dixon (Repository Guardian)
Mail Code: CR107
3181 SW Sam Jackson Park Rd.
Portland, OR 97239
byerlee@ohsu.edu
The participation of OHSU students or employees in OHSU research is completely voluntary and you are free to choose not to serve as a research subject in this protocol for any reason. If you do elect to participate in this study, you may withdraw from the study at any time without affecting your relationship with OHSU, the investigator, the investigator's department, or your grade in any course. If you would like to report a concern with regard to participation of OHSU students or employees in OHSU research, please call the OHSU Integrity Hotline at 1-877-733-8313 (toll free and anonymous).

Old Registration Date (for registrants before 3/6/2017)

M-D-Y

Registration Date (for registrants after 3/6/2017, 2017)

M-D-Y

Are you between the age of 18 and 89?

* must provide value

Yes

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Your submission of this electronic form by clicking on "I AGREE TO PARTICIPATE" indicates that you have read the entire Information Form and that you agree to be in this registry. If you change your mind about participation in the registry at any time, now or in the future, contact the study team listed on the first page of the consent form.

I have read the Information Sheet.

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I AGREE TO PARTICIPATE

I DO NOT WISH TO PARTICIPATE

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Name of Person Registering

First name (given name)

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Last name (family name)

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Click here to download a copy of the Information Sheet (OPTIONAL)

Please send me a printed version of the Information Sheet

Information Sheet

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