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Dep ar t me n t/ Se ct io n o f Dep a rt men t o r S ec tio n Na m e STUDY TITLE Assent Form Age 16-17 to Participate in Research First Name Last Name, Degree, Principal Investigator INTRODUCTION You are invited to be in a research study. Research studies are designed to gain scientific knowledge that may help other people in the future. You are being asked to take part in this study because you have condition or reason the subject is being recruited. Your participation is voluntary. Please take your time in making your decision as to whether or not you wish to participate. Ask your study doctor or the study staff to explain any words or information contained in this informed consent document that you do not understand. You may also discuss the study with your friends and family. WHY IS THIS STUDY BEING DONE? The purpose of this research study is to Describe the Reason the Study is Being Done [Example Applicable text:] Phase 1 studies: test the safety of drug/intervention and see what effects (good and bad) it has on you and your condition. or find the highest dose of drug that can be given without causing severe side effects. Phase 2 studies: find out what effects (good and bad) drug/intervention has on you and your condition. Phase 3, and comparative phase 4 and post-marketing studies: compare the effects (good and bad) of new drug/intervention with commonly-used drug/intervention to see which is better. [Other text describing the purpose of the study should be used as appropriate] [For studies involving an investigational drug or device] Investigational/Experimental drug or device is an investigational drug/device. This means it has not been approved by the U.S. Food and Drug Administration (FDA). Drugs and devices that do not have approval by the FDA cannot be sold or prescribed by your physician. Page 1 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 [For studies involving FDA approved drugs or devices used in an unlabeled manner] Drug or Device Name has been approved by the US Food and Drug Administration (FDA), but it has not been approved for use in this manner, at this dose, for this condition, for administration by this route or other text as appropriate. [For studies involving the use of placebo] In this study drug or device name will be compared to placebo. A placebo is a substance, like a sugar pill, that is not thought to have any effect on your disease or condition. In this study you will either receive the active study medication, drug or device name or placebo which is not active. Placebos are used in research studies to see if the drug being studied really does have an effect. HOW MANY PEOPLE WILL TAKE PART IN THE STUDY? number people at number of research sites will take part in this study, including approximately number people at this research site. Optional Sentence if applicable: In order to identify the (insert number) subjects needed, we may need to screen as many as (insert number) because some people will not qualify to be included in the study. WHAT IS INVOLVED IN THE STUDY? [Provide simplified schema and/or calendar such as “At your first study visit you will …”] [For randomized studies:] You will be randomized into one of the study groups described below. Randomization means that you are put into a group by chance. It is like flipping a coin. You will have an equal/one in three/etc. chance of being placed in any group. [For blinded studies] Neither you nor the investigator will know which study drug, device, procedure, treatment, etc. you are receiving. This is done so that a fair evaluation of results can be made. This information is available to the researchers if needed in an emergency. [Modify as appropriate for single blind studies] [For all studies describe step-by-step, what will be required of, or done to, the research subject. The description should be in lay language, defined as language understandable to the people being asked to participate (usually 6th to 8th grade). The use of second person (e.g., “You will receive…”) is generally required; the use the first person (e.g., "I understand that...") is generally not allowed.] If you take part in this study, you will have the following tests and procedures: [List study procedures and their frequencies, differentiating between those that will be performed solely for research or investigational purposes, and those that represent standard of Page 2 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 care. For randomized studies, list the study groups and under each, describe procedures. Include whether a patient will be at home, in the hospital, or in an outpatient setting. List the research medications that will be administered and the method, dose and frequency of administration. Indicate the number frequency and duration of visits. For studies involving non-FDA approved drugs or devices indicate whether the subject will have access to them following the completion of the study. Indicate other specific requirements such as post-treatment follow-up, diary cards, and questionnaires.] [Blood drawing] You will have approximately (state amount in teaspoons or tablespoons) of blood withdrawn from a vein (state frequency or number of occasions). The total amount of blood withdrawn during the study will be approximately (state amount in teaspoons or tablespoons or ounces). [For studies involving photography/video and audio taping as part of the study procedures] As part of this research study, you will be photographed/videotaped/audiotaped. This is being done [brief description of why this is necessary]. You understand that you may request the filming or recording be stopped at any time during the course of the research study. You can also withdraw your consent to use and disclose the photograph/videotape/audiotape before it is used. You should also understand that you will not be able to inspect, review, or approve the photographs, videotapes, audiotapes or other media (including articles containing such) before they are used in this study. Please choose one of the following regarding the use and disclosure of the photograph/videotape/audiotape used in this research study: _____ I would like the photographs/videotapes/audiotapes of me to be destroyed once their use in this study is finished. ____ The photographs/videotapes/audiotapes of me can be kept for use in future studies provided they are kept secure and any future study will be reviewed by an IRB. I understand that I will not be able to inspect, review or approve their future use. [For studies that plan on sending test results or findings to the subject’s personal physician include the following: NOTE: THE FOLLOWING TEXT IS REQUIRED FOR STUDIES WHICH ARE REQUIRED TO ADHERE TO ICH-GCP STANDARDS We can send copies of your test results to your personal physician. Even if you do not wish to have any of your medical information sent to your physician, you can still participate in this research study. Do you request that we send important medical findings from your study tests/exams to your personal physician? [ ] Yes [ ] No ___________ Initials Page 3 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 [If your study involves genetic testing, you must include the following text:] As part of this study, a blood sample will be obtained and DNA from your blood sample will be purified. DNA, or deoxyribonucleic acid, stores and transmits inherited traits, such as eye color or blood type. As part of this research project, your DNA will be studied in an effort to find out if there are genes that contribute to medical conditions that are part of this study. Because we do not know how the results of this DNA study relate to your individual health, the results of the research will not be given to you or your doctor without your permission. These results will also not be placed in your medical records. [If your study involves storage of biological material for future, undesignated research, you must include the following text:] Storage of Biological Tissue If you agree to participate in this study, we will (draw X amount of the blood or take tissue from your X) to use for future research. This sample will be kept and may be used in future research to learn more about other diseases. Your sample will be obtained (in what department) at Wake Forest University Baptist Medical Center. The sample will be stored (where) and it will be given only to researchers approved by (PI of study). An Institutional Review Board (IRB) must also approve any future research study using your tissue sample. In order to participate in this study, you must be willing to provide this sample for future research. (If providing a sample is NOT required, then the additional optional biospecimen consent form must be used for those who agree to provide samples) (Use this text for samples stored with a unique identifier) Your blood/tissue sample will be stored with a unique identifier and will not include any identifiable information about you such as your name, address, telephone number, social security number, medical record number or any of the identifiers outlined in the HIPAA Privacy Rule. The unique identifier will be a randomly assigned number and only the principal investigator will have access to the code that links the unique identifier to you. Your name, address, social security number, etc., will never be disclosed to future researchers and neither will the code that links your identifiers to the sample. (Use this text for samples stored de-identified) Your blood/tissue sample will be stored de-identified, which means that no identifying information will be stored with it. Researchers will not know the name, date of birth, medical record number, social security number, etc., of the person who donated the sample. The research that may be performed with your blood/tissue sample is not designed to help you specifically. There is no personal benefit to you from taking part in this aspect of the research study. It might help people who have diseases at some point in the future, but it is not known if this will happen. The results of the research performed with your blood /tissue will not be given to you or your doctor. The results will not be put in your medical record. The research using your blood/tissue sample will not affect your care. Your blood/tissue sample will be used only for research and will not be sold. The findings from this research may result in the future development of products that are of commercial value. Page 4 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 There are no plans to share any of the profits with you which may occur as a result of the research. (Use this text ONLY if samples are stored with identifiers) In the future, people who do research may need to know more about your health. While the study investigator may give reports about your health, he/she will NOT be given your name, address, phone number, or any other identifying information about who you are, unless you agree to be contacted in the future. ____YES you many contact for future research studies ____NO I do not want to be contacted regarding future research studies. [If your study involves whole genome testing, you must include the following text:] As part of the genetic study, a sample of your DNA may have Genome Wide Association Studies (GWAS) performed. This analysis creates a very detailed picture of your DNA for researchers. [If you are submitting samples/data to the NIH GWAS Repository, you must include the following text:] In addition, information regarding your DNA and clinical information about you will be sent to the National Institute for Health’s Genome Wide Association Study (GWAS) data repository, where it will undergo genome-wide analysis and be shared with other investigators for research purposes. DNA and information sent to the GWAS will help researchers better understand how genes affect the risk of developing diseases such as asthma, cancer, diabetes, and heart disease, and may lead to better methods to select the best treatment options. Before your information is sent to the GWAS data repository it will be de-identified, which means that we will remove any identifying information such as your name, date of birth, address, etc. Thus, researchers using your DNA and clinical data will not be able to link this information back to you. HOW LONG WILL I BE IN THE STUDY? You will be in the study for about months/weeks, until a certain event. [Where appropriate, state that the study will involve long-term follow up.] You can stop participating at any time. If you decide to stop participating in the study we encourage you to talk to the investigators or study staff first to learn about any potential health or safety consequences. [Describe any serious consequences of sudden withdrawal from the study.] WHAT ARE THE RISKS OF THE STUDY? Being in this study involves some risk to you. You should discuss the risk of being in this study with the study staff. Risks and side effects related to the procedures, drugs, or devices we are studying include: [Describe the immediate and long-term physical, psychological, social and reproductive risks/discomforts of participating in the study. Highlight or otherwise identify those that may be Page 5 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 irreversible, long-term or life threatening. Provide an estimate of the frequency of the risks/discomforts. If possible categorize risks/discomforts as Common, Uncommon, Rare, etc., as opposed to a long unbroken list of every side effect ever noted. ] In addition, there is a slight risk of a breach of confidentiality. We will do our best to protect your confidential information. There also may be other side effects that we cannot predict. You should tell the research staff about all the medications, vitamins and supplements you take and any medical conditions you have. This may help avoid side effects, interactions and other risks. [If the study involves the use of placebo, the possible consequences of not receiving active therapy must be discussed.] [If the study involves the withdrawal of active treatment for any reason (e.g. run-in phase, washout, changing therapy from standard active treatment to study treatment, or crossing over from one study arm to another) the consequences and risks of withholding, withdrawing or changing treatment must be discussed.] [For studies involving radiation] If you participate in this study, you will be exposed to amounts of radiation above what you would normally receive in daily life. To be sure that you do not receive an unhealthy amount of radiation from your participation in this study, you should let your study doctor know if you have had, or are going to have, any other scans or x-rays as part of your medical or dental care. It is very important that you let your study doctor know if you already are participating in, or plan to participate in, any other research study that involves radiation exposure. [If the study meets the definition of minimal risk:] The risk of harm or discomfort that may happen as a result of taking part in this research study is not expected to be more than in daily life or from routine physical or psychological examinations or tests. You should discuss the risk of being in this study with the study staff. [Security of confidentiality and privacy should be included for most studies] Taking part in this research study may involve providing information that you consider confidential or private. Efforts, such as coding research records, keeping research records secure and allowing only authorized people to have access to research records, will be made to keep your information safe. [For studies that involve psychological tests or interview questions related to depression, suicidal ideations, abuse, illegal behavior, or other information that may require reporting to authorities outside of the study, the following should be included:] As part of this study, you will be asked questions about [include the appropriate language depending on the test or activities to be performed] If we learn that you or someone else is in danger of harm, the study team is required to report that information to the proper authorities. Page 6 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 [When a Data Safety and Monitoring Committee exists:] A Data Safety and Monitoring Committee, an independent group of experts, will be reviewing the data from this research throughout the study. [For blood draws, include the following:] You may experience discomfort, bruising and/or bleeding where the needle is inserted. Occasionally some people become dizzy lightheaded or feel faint. Infection may occur on rare occasions. Frequent donation of blood can result in low iron in your blood (iron deficient anemia). [Optional – use only if applicable] If you donate blood to the American Red Cross, you should talk with the study doctor about whether or not it is safe to do so while participating in this study. You should not donate blood more than 2 times per week and no more than approximately one pint (about 500 ml) of blood in an eight week period. Reproductive Risks and other Issues to Participating in Research [Include the following if subjects include women of childbearing potential, and drug fetotoxic/fetocidal (or unknown), and illness non-terminal:] Due to unknown risks and potential harm to the unborn fetus, sexually active women of childbearing potential must use a reliable method of birth control while participating in this study. Reliable methods of birth control are: abstinence (not having sex), oral contraceptives, intrauterine device (IUD), DepoProvera, tubal ligation, or vasectomy of the partner (with confirmed negative sperm counts) in a monogamous relationship (same partner). An acceptable, although less reliable, method involves the careful use of condoms and spermicidal foam or gel and/or a cervical cap or sponge. We encourage you to discuss this issue further with your physicians if you have any questions. [If immediate treatment is required (less than 15 days from diagnosis), include the following phrase:] Pregnant women are excluded from participation in this study. Because some methods of birth control are not 100% reliable, a pregnancy test is required at least 10 days from your last normal menstrual period, if you are a sexually active woman of childbearing potential. [If immediate treatment is NOT required, include the following phrase:] Pregnant women are excluded from participation in this study. If you are a sexually active woman of childbearing potential and have not been using a reliable method of birth control, two negative pregnancy tests performed 15 days apart are required to check for possible early pregnancy prior to starting treatment. [If male subjects are included, and drug fetotoxic/fetocidal (or unknown) include the following Page 7 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 phrase:] Contraceptive Measures for Males Your participation in this research study may damage your sperm, which could cause harm to a child that you may father while on this study. Such harm may be currently unforeseeable. If you are sexually active, you must agree to use a medically acceptable form of birth control in order to be in this study and for (specify period of time following study participation if applicable) months afterwards. Medically acceptable contraceptives include: (1) surgical sterilization (such as a vasectomy), or (2) a condom used with a spermicide. Contraceptive measures such as Plan B (TM), sold for emergency use after unprotected sex, are not acceptable methods for routine use. You should inform your partner of the potential for harm to an unborn child. She should know that if pregnancy occurs, you will need to report it to the study doctor, and she should also promptly notify her doctor. [For studies that involve HIV, Hepatitis or testing for other communicable diseases which require reporting to the NC State Board of Health:] As part of this study, you will be tested for [include the appropriate language depending on the test or tests to be performed] HIV (human immunodeficiency virus, which is the virus that causes the acquired immunodeficiency syndrome [AIDS]); Hepatitis A, B, or C. You will be told of the results of the testing, and counseled as to the meaning of the results, whether they are positive or negative. If the test indicates that you are infected with [insert disease], you will receive additional counseling about the significance of your care and possible risks to other people. We are required by law to report all positive results to the North Carolina State Board of Health. The test results will be released only as permitted by applicable law. If you do not want to be tested for [insert disease], you should not agree to participate in this study. ARE THERE BENEFITS TO TAKING PART IN THE STUDY? [If the individual subject will receive no direct benefit from participating in the study] You are not expected to receive any direct benefit from taking part in this research study. We hope the information learned from this study will benefit other people in the future. [If the individual subject may receive some direct benefit from participating in the study] If you agree to take part in this study, there may or may not be direct benefit to you. We hope the information learned from this study will benefit other people in the future. The benefits of participating in this study may be: [Describe the benefits an individual subject could reasonably expect from participating in the study. Payments, incentives, or other forms of remuneration offered to potential subjects should not be considered a benefit to be gained from research.] [When appropriate:] Based on experience with [drug, procedure, device, etc.] in [animals, other research studies, patients with other disorders, patients with similar disorders], researchers believe [it may be as good as standard therapy you could receive without being in the study but with fewer side effects, it may be of benefit to subjects with your condition, or other appropriate text]. Because Page 8 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 individuals respond differently to therapy, no one can know in advance if it will be helpful in your particular case. WHAT OTHER CHOICES ARE THERE? You do not have to be in this study to receive treatment. You should talk to your doctor about all the choices you have. Instead of being in this study, you have these options: [List commonly available alternatives] [If the study involves non-investigational treatments] You could be treated with study treatments/drugs even if you do not take part in the study. [If the study is a non-therapeutic study where the only option is to not participate] This is not a treatment study. Your alternative is to not participate in this study. THE FOLLOWING TEXT IS REQUIRED FOR STUDIES WHICH ARE REQUIRED TO ADHERE TO ICH-GCP STANDARDS: List the most common standard of care alternative procedures and most substantial risks and benefits of the standard of care procedures. WHAT ARE THE COSTS? [Use one of the following paragraphs as appropriate:] All study costs, including any study medications and procedures related directly to the study, will be paid for by the study. Costs for your regular medical care, which are not related to this study, will be your own responsibility. [If there is any standard of care billing, in addition to research charges, include the following paragraph:] Taking part in this study may lead to added costs to you or your insurance company. We will give you an estimate of what the added cost may be based on your particular situation and insurance coverage. [For studies utilizing a medical device, please insert the most appropriate option from the ones listed below:] Device provided by Sponsor (and professional services to implant device will (or will not) be billed to patient/insurer): “Neither you nor your insurance company will be billed for the investigational device. You and/or your insurance company will (or will not) be billed for the cost of any surgical procedure(s) necessary to implant the (name of device).” Device to be billed to patient/insurer: “You or your insurance company will be billed for the investigational device. You and/or your insurance company will (or will not) be billed for the cost of any surgical procedure(s) necessary to implant the (name of device).” Page 9 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 Billing of device is dependent upon randomization: If you are assigned to the (Name of Device) group, you will not be charged for the (Name of device) device.” If you are assigned to the (Name of device) group, you will be charged for the (Name of device) device.” WILL YOUR RESEARCH RECORDS BE CONFIDENTIAL? The results of this research study may be presented at scientific or medical meetings or published in scientific journals. Your identity and/or your personal health information will not be disclosed unless it is authorized by you, required by law, or necessary to protect the safety of yourself or others. There is always some risk that even de-identified information might be re-identified. Participant information may be provided to Federal and other regulatory agencies as required. The Food and Drug Administration (FDA), for example, may inspect research records and learn your identity if this study falls within its jurisdiction. [If this study falls within the jurisdiction of the Food and Drug Administration, include following statement:] The purpose of this research study is to obtain data or information on the safety and/or effectiveness of (insert name of drug, device, etc.); the results will be provided to the sponsor, the Food and Drug Administration and other federal and regulatory agencies as required. [For studies that involve the recording of audio or video, describe how the recordings will be stored, how long the recordings will be retained and include a statement that during study activities subjects may request that recordings be stopped at any time.] [For studies that involve group interviews or focus groups, include a statement explaining that subjects do not have to use their real name during the discussions. They can use a fictitious name. In addition, include a statement explaining that subjects participating in group interviews or focus groups must agree not to disclose any information talked about in the group to protect the confidentiality of all participants.] [For clinical trials or other studies involving health-related tests or interventions that could affect clinical care, include the following statement:] If you choose to participate in this study, your medical record at Wake Forest University Baptist Medical Center will indicate that you are enrolled in a research study. Information about the research and any medications or devices you are being given as a participant may also be included in your medical record. This part of the medical record will only be available to people who have authorized access to your medical record. If you are not a patient at this Medical Center, a medical record will be created for you anyway to ensure that this important information is available to doctors in case of an emergency. Page 10 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 WILL YOU BE PAID FOR PARTICIPATING? [If compensation for participation is available, list conditions, such as dollar amount per visit or payment upon study completion.] You will be paid $$ if you complete all the scheduled study visits. If you withdraw for any reason from the study before completion you will be paid $$ for each complete study visit. [Include the following for studies where compensation is more than $50] To receive payment, you must provide your social security number, name and address so that we can comply with IRS (Internal Revenue Service) reporting requirements. When payments are reported to the IRS we do not let them know what the payment is for, only that you have been paid. If you do not wish to provide this information you can still take part in this study but you will not be paid. [If no payment for participation is available, including the following:] You will receive no payment or other compensation for taking part in this study. [Unless no commercial development is expected to arise from the study including the following:] The findings from this research may result in the future development of products that are of commercial value. There are no plans to provide you with financial compensation or for you to share in any profits if this should occur. WHO IS SPONSORING THIS STUDY? This study is being sponsored by [Name of the drug or device company, the National Institutes of Health, Wake Forest University Health Science, etc.]. The sponsor is providing money or other support to Wake Forest University Health Sciences to help conduct this study. The researchers do not, however, hold a direct financial interest in the sponsor or the product being studied. [When appropriate, the last sentence should be modified or expanded to disclose the nature of any potential or actual conflict relating to the study] WHAT HAPPENS IF YOU EXPERIENCE AN INJURY OR ILLNESS AS A RESULT OF PARTICIPATING IN THIS STUDY? [For research studies involving no greater than minimal risk of harm a statement is not required regarding whether any compensation and any medical treatment(s) are available if injury occurs.] [For all industry sponsored research studies (drugs and devices) include the following paragraph or the single-sentence response indicating that the injury language will provided following sponsor and G&CA approval] [SPONSOR] shall reimburse for reasonable and necessary medical expenses (the “Covered Expenses”) incurred by research subjects for medical care, including hospitalization, in the treatment of adverse reactions arising from study drugs, devices, intervention, procedures and tests following their administration or use in accordance with the protocol, which expenses were not caused by negligence or misconduct of any person in the employment of Wake Forest Page 11 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 University Health Sciences or to your own failure to follow instructions. The [SPONSOR] is not responsible for expenses that are due to pre-existing medical conditions or underlying disease. If you are injured, the sponsor may require information such as your name, social security number, and date of birth in order to pay for your care. This is because the sponsor is required by law to report any payments made to cover the care of any persons who are members of a government insurance plan to the Department of Health and Human Services. [The single-sentence response below indicating that the injury language will provided following sponsor and G&CA approval should be used only if the template above has already been rejected by the sponsor and negotiation of appropriate language is not yet complete] Injury language will be provided following completion of negotiation and approval by Sponsor and WFUHS. [For NIH, Foundation and Departmentally Sponsored Studies greater than minimal risk include the following paragraph] Should you experience a physical injury or illness as a direct result of your participation in this study, Wake Forest University School of Medicine maintains limited research insurance coverage for the usual and customary medical fees for reasonable and necessary treatment of such injuries or illnesses. To the extent research insurance coverage is available under this policy the reasonable costs of these necessary medical services will be paid, up to a maximum of $25,000. Wake Forest University Baptist Medical Center holds the insurance policy for this coverage. It provides a maximum of $25,000 coverage for each claim and is limited to a total of $250,000 for all claims in any one year. The Wake Forest University School of Medicine, and the North Carolina Baptist Hospitals, Incorporated do not assume responsibility to pay for these medical services or to provide any other compensation for such injury or illness. Additional information may be obtained from the Medical Center’s Director of Risk and Insurance Management, at (336) 716-3467. If you are injured, the insurer may require information such as your name, social security number, and date of birth in order to pay for your care. This is because the insurer is required by law to report any payments made to cover the care of any persons who are members of a government insurance plan to the Department of Health and Human Services. You do not give up any legal rights as a research participant by signing this consent form. For more information on medical treatment for research related injuries or to report a study related illness, adverse event, or injury you should call PI’s Name at telephone number (also include after hours number.] What About My Health Information? Select text in red italics as applicable. Provide information highlighted in yellow. Page 12 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 In this research study, any [new information we collect from you] and/or [information we get from your medical records or other facilities] about your health or behaviors is considered Protected Health Information. The information we will collect for this research study includes: [List information that will be collected]. If this research study involves the diagnosis or treatment of a medical condition, then Protected Health Information collected from you during this study will be placed in your medical record, and may be used to help treat you, arrange payment for your care, or assist with Medical Center operations. (Use “may” if there is no intention to collect clinically relevant information and place it in the medical record and “will” if the study is intended to produce or address clinically relevant information that should be included in the medical record for subject health). We will make every effort to keep your Protected Health Information private. We will store records of your Protected Health Information in a cabinet in a locked office or on a password protected computer. Your personal health information and information that identifies you (“your health information”) may be given to others during and after the study. This is for reasons such as to carry out the study, to determine the results of the study, to make sure the study is being done correctly, to provide required reports and to get approval for new products. Some of the people, agencies and businesses that may receive and use your health information are the research sponsor; representatives of the sponsor assisting with the research; investigators at other sites who are assisting with the research; central laboratories, reading centers or analysis centers; the Institutional Review Board; representatives of Wake Forest University Health Sciences and North Carolina Baptist Hospital; representatives from government agencies such as the Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS) and similar agencies in other countries. Some of these people, agencies and businesses may further disclose your health information. If disclosed by them, your health information may no longer be covered by federal or state privacy regulations. Your health information may be disclosed if required by law. Your health information may be used to create information that does not directly identify you. This information may be used by other researchers. You will not be directly identified in any publication or presentation that may result from this study unless there are photographs or recorded media which are identifiable. THE FOLLOWING TEXT IS REQUIRED FOR STUDIES WHICH ARE REQUIRED TO ADHERE TO ICH-GCP STANDARDS: 1) Monitors, auditors, IRB or other regulatory agencies will be granted direct access to the participant’s original medical record for verification of clinical trial procedures or data, without violating confidentiality of the participant and to the extent permitted by other applicable laws. Page 13 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 2) When a study involves the use of a drug, device, or FDA regulated product insert: Representatives from government agencies such as the US Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS), and [List specific agencies]. 3) When a study involves funding from a government agency insert: Representatives from government agencies such as the Office for Human Research Protections and other similar agencies. 4) [List other individuals, organizations, agencies, etc as applicable for the particular study.] If required by law or court order, we might also have to share your Protected Health Information with a judge, law enforcement officer, government agencies, or others. If your Protected Health Information is shared with any of these groups it may no longer be protected by federal or state privacy rules. Any Protected Health Information collected from you in this study that is maintained in the research records [will be kept for at least six years after the study is finished. At that time any research information not already in your medical record will either be destroyed or it will be deidentified] or [will be kept for an indeterminate period of time. This authorization does not expire] and/or [Any research information entered into your medical record will be kept for as long as your medical record is kept by the Medical Center]. You will not be able to obtain a copy of your Protected Health Information in the research records until all activities in the study are completely finished. (The first option should be selected if Wake Forest investigators are conducting the study and will determine the end-date. The second option should be used if the study is sponsored and it is unclear when the data will no longer be need in support of a new drug, device, or other medical improvement – and/or if there are video tapes or images being collected that will not be destroyed following the completion of the study. The third sentence should be included if there is a likelihood that data will be included in the subject’s medical record). You can tell [Principle Investigator's Name ] that you want to take away your permission to use and share your Protected Health Information at any time by sending a letter to this address: Principal Investigator Name Address City, State, Zip However, if you take away permission to use your Protected Health Information you will not be able to be in the study any longer. We will stop collecting any more information about you, but any information we have already collected can still be used for the purposes of the research study. Page 14 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 By signing this form you give us permission to use your Protected Health Information for this study. [If this study is a Clinical Trial the following language should be included] If you choose to participate in this study, your medical record at Wake Forest University Baptist Medical Center will indicate that you are enrolled in a clinical trial. Information about the research and any medications or devices you are being given as a participant may also be included in your medical record. This part of the medical record will only be available to people who have authorized access to your medical record. If you are not a patient at this Medical Center, a medical record will be created for you anyway to ensure that this important information is available to doctors in case of an emergency. A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by U.S. Law. This website will not include information that can identify you. At most, the website will include a summary of the results. You can search this Web site at any time. (This language is required by the FDA for all applicable clinical trials.) [For studies involving tests or procedures that may be scheduled or reported using the Medical Center computer system the investigator should include the following] Laboratory test results and other medical reports created as a result of your participation in the research study may be entered into the computer systems of Wake Forest University Health Sciences and North Carolina Baptist Hospital. These will be kept secure, with access to this information limited to individuals with proper authority, but who may not be directly involved with this research study. A North Carolina Baptist Hospital (NCBH) medical record will be created for all study participants. Information about your participation in the study will be placed in the NCBH medical record, along with any routine medical test results that were obtained at NCBH as part of this study. WHAT ARE MY RIGHTS AS A RESEARCH STUDY PARTICIPANT? Taking part in this study is voluntary. You may choose not to take part or you may leave the study at any time. Refusing to participate or leaving the study will not result in any penalty or loss of benefits to which you are entitled. If you decide to stop participating in the study we encourage you to talk to the investigators or study staff first to learn about any potential health or safety consequences. The investigators also have the right to stop your participation in the study at any time. This could be because [List circumstances, such as, it is in your best medical interest, your condition worsened, new information becomes available, you had an unexpected reaction, you failed to follow instructions, or because the entire study has been stopped]. You will be given any new information we become aware of that would affect your willingness to continue to participate in the study. Page 15 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 If you are recruiting medical or graduate students, please include the following paragraph: This study will be enrolling students from the ___________ campus (choose Wake Forest University and/or Wake Forest University Medical Center). In addition to your rights as a research participant noted in the previous section, as a student, you are under no obligation to participate in this study. You may refuse to participate or withdraw from the study at any time and for any reason without affecting your grades, performance evaluations, or assignments. You will not be pressured into participating in this research study by any statements or implied statements that your grades, performance evaluations or assignments will be affected by your willingness to enroll in the study. Your medical records/information will not be used by the faculty, administration or study staff to make decisions regarding the status of your medical benefits. If you have questions regarding your enrollment in the study and your status as a medical student, please contact the Office of Student Services for additional information. Whom Do I Call if I Have Questions or Problems? For questions about the study or in the event of a research-related injury, contact the study investigator, Name at telephone number (also include after hours number). The Institutional Review Board (IRB) is a group of people who review the research to protect your rights. If you have a question about your rights as a research participant, or you would like to discuss problems or concerns, have questions or want to offer input, or you want to obtain additional information, you should contact the Chairman of the IRB at (336) 716-4542. You will be given a copy of this signed assent form. SIGNATURES I agree to take part in this study. I authorize the use and disclosure of my health information as described in this assent and authorization form. If I have not already received a copy of the Privacy Notice, I may request one or one will be made available to me. I have had a chance to ask questions about being in this study and have those questions answered. By signing this assent and authorization form, I am not releasing or agreeing to release the investigator, the sponsor, the institution or its agents from liability for negligence. Subject Name (Printed):_________________________________ Subject Signature: _____________________________________ Date: ________Time:____am pm Page 16 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16 Person Obtaining Assent (Printed):_____________________________ Signature of Person Obtaining Assent:_______________________ Date:_________Time:____ am pm Page 17 of 17 Assent Form Age 16-17 Version: _____________ IRB Template Version 3.21.16