Consent Form ED Study Database

 
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CONSENT FORM
If you are interested in being contacted for participation in future eating disorder research studies, we would like to invite you to enter your contact information and answer questions regarding your eating disorder symptomology and demographics. We ask that you read this form and ask any questions you may have before agreeing to have your information entered into the recruitment log.

Study Purpose

The recruitment log will be used to identify potential participants for eating disorder research studies based on study eligibility and participants’ interests.

Study Procedures

If you choose to participate in the recruitment log, you will be asked to complete a series of questions. These questions will be administered online and will ask about your demographics and eating disorder symptoms.  The questions will take approximately 30 seconds to complete.

Risks of Study Participation

The questions could cause possible distress. If this happens, you can choose not to answer specific questions. You can also choose to withdraw at any time.

There is also a small risk that there would be a breach of confidentiality. Every precaution will be taken to avoid this.  All data, including name, email and phone number, are stored on secure computer databases.

Benefits of Study Participation

We cannot guarantee that you will directly benefit from this study, but by entering requested information we may be able to contact you for research studies that are most applicable to you.

Alternatives to Study Participation

Participation in this study is voluntary. You can choose to not participate or to withdraw at any time.

Study Costs/Compensation

There is no cost to you for participating in this study.

Research Related Injury

In the event that this research activity results in an injury, treatment will be available, including first aid, emergency treatment and follow-up care as needed. Care for such injuries will be billed in the ordinary manner to you or your insurance company. If you believe that you have sustained injury as a result of participating in a research study, you may contact the Principal Investigator, Dr. Crow, at 612-625-1838 so that you can review the matter and identify the medical resources that may be available to you.

Confidentiality

Records of this study will be kept private and any publications or presentations will not include any information that will make it possible to identify you as a subject. Your records for the study may, however, be reviewed by departments at the University of Minnesota with appropriate regulatory oversight.  To this extent confidentiality is not absolute.   Study data will be encrypted according to current University policy for the protection of confidentiality.

Protected Health Information (PHI)

Your PHI created or received for the purposes of this study is protected under the federal regulation known as HIPAA.  Please refer to the HIPAA authorization form that you will see after completing the consent form for details concerning the use of this information. 

Voluntary Nature of the Study

Participation in this study is voluntary.  Your decision about participating in this study will not affect your current or future relationships with the University of Minnesota or The Emily Program.  If you decide to participate you are free to withdraw at any time without affecting those relationships.
Contacts and Questions

The researchers conducting this study are Scott Crow, M.D., Carol Peterson, Ph.D., and Emily Pisetsky, Ph.D. If you have questions you are encouraged to contact Dr. Crow at 612-273-9807.

If you have any questions or concerns regarding the study and would like to talk to someone other thanthe researcher(s), you are encouraged to contact the Fairview Research Helpline at telephone number 612-672-7692 or toll free at 866-508-6961.  You may also contact this office in writing or in person at Fairview Research Administration, 2344 Energy Park Drive, St. Paul, MN  55108.
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