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Clinical Research Recruitment - Consent

Please review the consent form and complete the survey.

Once you submit the survey, our research team will be notified of your registration in our database.

Thank you!

ADULT/PARENT CONSENT
We are recruiting research participants to help us establish a list or database of patients who may qualify for and may be interested in participating in future studies at KUMC. Participation involves disclosing contact information with the Internal Medicine Clinical Research team.

We will ask you to complete a form with your name, date of birth, gender, phone numbers, email, and areas of interest for potential clinical research participation. This information will be stored indefinitely in a secured database at KUMC. If you potentially qualify for a study either today or in the future, we may ask if you are interested in coming in for additional screening procedures to further determine your eligibility. Being listed in our database and being in any future studies is voluntary.

You can decline or stop at any time without penalty.

You will not receive any personal benefit from participating in this database. Being in this database will allow KUMC researchers to contact you for potential participation research studies relating to sub specialties within internal medicine.

The only risks in providing your personal information to this database relates to the confidentiality of your health information. We will follow the HIPAA laws about privacy. Your personal information will be shared with members of the research team. It might also be seen by persons at KUMC or government officials who monitor research if there was an audit. We will do our best to protect the privacy of your information. We will store your information in a password protected and secure database in a locked office. We will keep your survey information indefinitely.

If you want to cancel your permission to use your health information, please write to Matthias Salathe, MD. The mailing address is Matthias Salathe, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160. If you cancel permission to use your health information, you will be withdrawn from the database.

If you have any questions, please contact us at (913) 588-6045. For questions about the rights of research participants, you may contact the KUMC Institutional Review Board (IRB) at (913) 588-1240 or irbhelp@kumc.edu.

Are you consenting for:

Yourself

Your Child

Both

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Do you give your permission for your personal information to be stored in our database and to be contacted for future research studies?

* must provide value

Yes

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* must provide value

Add signature

Adult First Name

* must provide value

Adult Last Name

* must provide value

Adult Gender

* must provide value

Male

Female

Other

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If other, please specify

* must provide value

Adult Date of birth

* must provide value

M-D-Y

Adult Phone number

* must provide value

Adult Email

* must provide value

How do you prefer to be contacted?

* must provide value

Phone

Both

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What area of research are you interested in?

* must provide value

All of Us Research Program (AoU)

Allergy and Immunology

Cigarette & e-Cigarette Smoking

Clinical Pharmacology

Dermatology

Diabetes

Endocrinology & Metabolism

Gastroenterology, Hepatology & Motility

Genetic, Environmental, & Inhalation

Geriatrics

Hematologic Malignancies and Cellular Therapeutics

Hypertension

Infectious Diseases

Kidney Transplant

Medical Oncology

Nephrology

Otolaryngology (Ear, Nose, & Throat)

Palliative Medicine

Precision & Prevention

Pulmonary & Critical Care

Sleep Medicine

Weight Management

Healthy Volunteer

Other

If other, please specify

* must provide value

If other, please comment

* must provide value

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If you have a specific clinical trial you are interested in, please provide details from our website or other sources.

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Are you (also) providing consent for your child?

* must provide value

Yes

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Is your child between the ages of 11-17 and able to provide assent?

* must provide value

Yes

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You may proceed with providing consent on behalf of your child. Children 10 years old and under are not required to provide assent.

You are a parent or legal guardian of a child and want to enroll them in a research registry. You are being asked to provide permission for your child to participate in the registry described in this consent form.

By signing this form, you agree that Dr. Salathe or the study team have given you the information you need to make your decision. The study team has explained what will happen in the research with your child. They explained any inconvenience, discomfort or risks that your child may experience.

By signing this form, you are granting permission for your child to participate in this research registry. You have read the information and had your questions answered.

* must provide value

Add signature

Your child will be requested to review the Assent Form and provide assent to share his/her information with the research team.

ASSENT FOR CHILDREN (11 years and older)
We are collecting a list of people who are willing to let us store information about them in our computers. If you agree to be on the list we will call your parent/guardian to ask more questions about your health later. We may also call to see if you are interested in being apart of other studies in the future.

You do not have to be on the list if you do not want to. No one will be mad at you if you do not want to be on the list. If you decide to be on the list and later change your mind, you can stop at any time. You do not have to be part of any of the studies we may call you about in the future if you do not want to.

Your parents/guardian and you have been told about the list, and you understand what will be done. You have asked any questions that you can think of right now. You can ask more questions if you think of them later.

CHILD ASSENT
Do you give your permission for your personal information to be stored in our database and to be contacted for future research studies?

Yes

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Your child declined participation on assent form. His(her) information will not be recorded in our database.

Child signature for assent

* must provide value

Add signature

First name of parent

* must provide value

Last name of parent

* must provide value

First Name (Child)

* must provide value

Last name (child)

* must provide value

Gender (child)

* must provide value

Male

Female

Other

reset

If other, please specify

* must provide value

Date of birth (child)

* must provide value

D-M-Y

Phone number (parents)

* must provide value

Email (parents)

* must provide value

How do you prefer to be contacted?

* must provide value

Phone

Both

reset

What area of research are you interested in for your child?

* must provide value

All of Us Research Program (AoU)

Allergy and Immunology

Cigarette & e-Cigarette Smoking

Clinical Pharmacology

Dermatology

Diabetes

Endocrinology & Metabolism

Gastroenterology, Hepatology & Motility

Genetic, Environmental, & Inhalation

Geriatrics

Hematologic Malignancies and Cellular Therapeutics

Hypertension

Infectious Diseases

Kidney Transplant

Medical Oncology

Nephrology

Otolaryngology (Ear, Nose, & Throat)

Palliative Medicine

Precision & Prevention

Pulmonary & Critical Care

Sleep Medicine

Weight Management

Healthy Volunteer

Other

If other, please specify

* must provide value

If other, please comment

* must provide value

Expand

If you have a specific clinical trial you are interested in, please provide details from our website or other sources.

Expand

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.