ALBERT EINSTEIN COLLEGE OF MEDICINE OF YESHIVA
MONTEFIORE MEDICAL CENTER
JACOBI MEDICAL CENTER
NORTH CENTRAL BRONX HOSPITAL
SIMPLIFIED INFORMED CONSENT DOCUMENT
Title of Research Study:
Principal Investigator (Researcher):
Phone Number of Investigator:
Purpose: (Why you are here?)
You are not feeling well and we want to help find out more about your
sickness and help us understand which medicine may help you and other people
Procedures: (What will happen?)
We will give you some medicine to take at home. We ask you to come back to see the doctor one time each week for the next eight weeks. When you come back, the doctor will take some of your blood, about ½ teaspoon. The doctor will clean you arm and stick your arm with a needle. The doctor or nurse may ask you to pee into a cup so that we can test your urine. You may also be asked some questions about how you feel.
Your family member is also being asked to give permission for the research in which you will participate.
Risks: (Will it hurt?)
No, the test is safe and does not hurt. OR, Yes, the needle stick may hurt a little. OR, The questions may make you sad or embarrass you.
Benefits: (How may it help you?)
The research study will not help you feel better. However, the information the researchers learn may help other people in the future.
Alternative Procedures: (Can you say "No"?)
Yes. You do not have to do the if you do not want to. You can stop at any time you want. You do not have to answer any question that makes you feel uncomfortable or sad. No one will be upset with you if you say “no” or if you say “yes” and then change your mind.
You have been told about the research study.
You have been told what you have to do.
You have been told that you do not have to do any of the tests if you do not want to.
You have also been told that you can stop any time you want, even after you begin.
The signature section is specially formatted - please do not modify.
|Name of Participant||Signature of Participant||Date|
|Name of Family Member||Signature of Family Member||Date|
|Name of Person Conducting the Informed Consent Process||Signature of Person Conducting the Informed Consent Process||Date|