Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 333 views

    Appendix A - Consent Form

    Uploaded by

    Shehryar Khalid
    This consent form summarizes a research study assessing different smoking cessation methods at Wyckoff Heights Medical Center. Participants will be asked to fill out a survey after one month. Any information provided will remain confidential. Participation is voluntary and participants can withdraw at any time without consequences.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Appendix A - Consent Form

    Uploaded by

    Shehryar Khalid
    333 views2 pages
    This consent form summarizes a research study assessing different smoking cessation methods at Wyckoff Heights Medical Center. Participants will be asked to fill out a survey after one month. Any information provided will remain confidential. Participation is voluntary and participants can withdraw at any time without consequences.

    Original Description:

    Smoking Cessation Consent Form

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This consent form summarizes a research study assessing different smoking cessation methods at Wyckoff Heights Medical Center. Participants will be asked to fill out a survey after one month. Any information provided will remain confidential. Participation is voluntary and participants can withdraw at any time without consequences.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    333 views2 pages

    Appendix A - Consent Form

    Uploaded by

    Shehryar Khalid
    This consent form summarizes a research study assessing different smoking cessation methods at Wyckoff Heights Medical Center. Participants will be asked to fill out a survey after one month. Any information provided will remain confidential. Participation is voluntary and participants can withdraw at any time without consequences.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Consent Form for Smoking Cessation Research

    Consent to Participate in Research


    Title of study: Comparative assessment of Smoking Cessation Methodology You are asked to participate in a research study conducted by the Family Medicine Department at Wyckoff Heights Medical Center, Brooklyn. You were selected as a possible participant in this study because of your fluency in English Language.

    Purpose of the Study


    The study is designed to assess the smoking cessation methodology in the Wyckoff heights medical center community

    Patient Participation
    You will be asked to fill out a survey at the end of one month.

    Benefits
    The data collected will be used to improve smoking cessation methods in our community.

    Confidentiality
    Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law and HIPPA.

    Participation and Withdrawal


    You can choose whether to be in this study or not. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. Participation or non-participation will not affect your or any other personal consideration or right you usually expect. You may also refuse to answer any questions you don't want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise which in the opinion of the researcher warrant doing so.

    Identification of Investigators
    If you have any questions or concerns about the research, please feel free to contact Wyckoff Heights Medical Center, Family Medicine Department.

    Rights of Research Subjects


    You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims, rights or remedies because of your participation in this research study. 1|Page

    Legal Use
    You agree not to use any information regardimg this study for any legal action or in any legal matters current or in the future. SIGNATURE OF RESEARCH SUBJECT (AND) OR LEGAL REPRESENTATIVE I understand the procedures and conditions of my participation described above. My questions have been answered to my satisfaction, and I agree to participate in this study. I have been given a copy of this form. Name of Subject: Name of Legal Representative (if applicable):

    Signature of Subject or Legal Representative:

    Date: Statement and Signature of Investigator Note: The IRB will normally require that the investigator sign the following statement when the risk to subjects is greater than minimal or when physically invasive procedures will be used or when there is a probability* of some subjects being of diminished autonomy. * Probability in this situation means at least one standard deviation greater than mean statistical possibility. In my judgment the subject is voluntarily and knowingly giving informed consent and possesses the legal capacity to give informed consent to participate in this research study.

    Signature of Investigator:

    Date:

    2|Page

    You might also like