Cancer Prevention and Research Institute of Texas (CPRIT)
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Instructions:
WRITTEN STATEMENT OF CONSENT
Thank you for your engagement with Texas Southern University Center Breast Cancer Screening and Prevention Center (TSU BCSPC). You are now invited to participate in TSU BCSPC’s continual efforts to offer quality services by completing and submitting a brief survey about your attendance at this event.
Description: TSU BCSPC offers quality Breast cancer awareness and education, Breast cancer screening/diagnostic services, and Patient navigation/barrier reduction services. The brief survey is anonymous consisting of twenty-four (24) questions which should take approximately 15 minutes or less to complete. Responses will be compiled and shared in summary form.
Risk: The probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life.
Benefits: Direct benefits include obtaining access to TSU BCSPC information, resources and referrals at no cost, as needed. There are no participant incentives or compensation for completing and submitting the post-event survey.
Voluntary Participation: Your participation is voluntary or you may choose to not participate at all. You will not be penalized in any manner for not submitting the feedback form.
Confidentiality: Your identity will not be attached to the data (you will remain anonymous).
Records (Physical): Hardcopy data will be stored on the campus of Texas Southern University, within the College of Pharmacy & Health Sciences, Room 123 in a locked file cabinet, accessible only to the investigator.
Records (Electronic): Electronic data records will be password protected, accessible only to the investigator.
Should you have questions or need additional information, you may contact CEC Director, Dr. Veronica Ajewole, by phone
at 713.313.1217 or by email at Veronica.Ajewole@tsu.edu.
If you have questions about your rights as a research subject, please contact Texas Southern University Committee for the Protection of Human Subjects at 713.313.4301 or go to
http://www.tsu.edu/research.
Completing and submitting the brief survey implies your consent in that you are 18+ years of age, have read this document
and would like to voluntarily participate.
We thank you in advance for helping us serve you better.
Thank you for your engagement with Texas Southern University Center Breast Cancer Screening and Prevention Center (TSU BCSPC). You are now invited to participate in TSU BCSPC’s continual efforts to offer quality services by completing and submitting a brief survey about your attendance at this event.
Description: TSU BCSPC offers quality Breast cancer awareness and education, Breast cancer screening/diagnostic services, and Patient navigation/barrier reduction services. The brief survey is anonymous consisting of twenty-four (24) questions which should take approximately 15 minutes or less to complete. Responses will be compiled and shared in summary form.
Risk: The probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life.
Benefits: Direct benefits include obtaining access to TSU BCSPC information, resources and referrals at no cost, as needed. There are no participant incentives or compensation for completing and submitting the post-event survey.
Voluntary Participation: Your participation is voluntary or you may choose to not participate at all. You will not be penalized in any manner for not submitting the feedback form.
Confidentiality: Your identity will not be attached to the data (you will remain anonymous).
Records (Physical): Hardcopy data will be stored on the campus of Texas Southern University, within the College of Pharmacy & Health Sciences, Room 123 in a locked file cabinet, accessible only to the investigator.
Records (Electronic): Electronic data records will be password protected, accessible only to the investigator.
Should you have questions or need additional information, you may contact CEC Director, Dr. Veronica Ajewole, by phone
at 713.313.1217 or by email at Veronica.Ajewole@tsu.edu.
If you have questions about your rights as a research subject, please contact Texas Southern University Committee for the Protection of Human Subjects at 713.313.4301 or go to
http://www.tsu.edu/research.
Completing and submitting the brief survey implies your consent in that you are 18+ years of age, have read this document
and would like to voluntarily participate.
We thank you in advance for helping us serve you better.