BCNS Survey

Consent

 
1. EXPLANATION OF RESEARCH

Title of Project: Application Of Complex Adaptive Systems Research Methodology to Basal Cell Nevus Syndrome

Principal Investigator: Amy Iarrobino, Morgan Stines, & Renee Domozych

Faculty Supervisor: James A Solomon, MD, PhD

You are being invited to take part in a research study. Whether you take part is up to you.

• The purpose of this research is to identify subpopulations among patients with Basal Cell Nevus Syndrome, clarify risk of advanced basal cell carcinoma among these subpopulations and elucidate incidence of other factors such as concomitant disease, treatments and disease manifestations.

• You will be asked to answer a series of questions about your past medical history, background and lifestyle.

• You will need approximately 40 minutes to complete the survey. Answer to the best of your knowledge for each question.

• Patients taking vismodegib or other hedgehog pathway inhibitors should respond according to what would be if the drug was not being taken.

You must be 18 years of age or older to take part in this research study.

Study contact for questions about the study or to report a problem: If you have questions, concerns, or complaints: James A Solomon, MD, PhD, Faculty Supervisor University of Central Florida, Directory of Ameriderm Research (386)523-0768, or by e-mail drjsolomon@ameridermresearch.com

IRB contact about your rights in the study or to report a complaint: Research at the University of Central Florida involving human participants is carried out under the oversight of the Institutional Review Board (UCF IRB). This research has been reviewed and approved by the IRB. For information about the rights of people who take part in research, please contact: Institutional Review Board, University of Central Florida, Office of Research & Commercialization, 12201 Research Parkway, Suite 501, Orlando, FL 32826-3246 or by telephone at (407) 823-2901.

Do you agree to continue with the study?
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