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Consent Form Checklist for Initial Review for WIRB Studies October 2015 Please use the Consent Form template for specific language to be added to your consent. Use this form to indicate what sections have been added to your consent document. Please acknowledge that you have addressed each consent section listed below. Acknowledged Consent Form Section Procedures: Please verify that the following information has been included in the consent document Number of study visits Length of study visits How long subjects will be enrolled in study Number of subjects from UW-Madison Risks and Discomforts: Please select which section(s) are included with your consent document Imaging Studies Laboratory Testing May Reveal Sexually Transmitted or other Communicable Diseases Protocol Specifically Tests for HIV, Hepatitis B and C Information About Illicit Drug Use and Alcohol Abuse Certificate of Confidentiality Will Be or Has Been Obtained Pregnancy Testing in Minors Confidentiality: Please indicate whether an optional sponsor statement is include in your consent document Sponsor statement included Sponsor did not include an additional statement Costs: Please indicate whether subjects may be billed for pharmacy dispensing charges. Subjects may be billed for pharmacy dispensing charges and the required language is included in the consent document Subjects will not be billed for pharmacy dispensing charged Commercial Products: Please indicate whether this study includes blood or tissue banking. This study includes banking and the required commercial products language is included in the consent document. This study does not include banking. Tissue Stored for Research: Please indicate the type of blood and/or tissue banking associated with this study Optional Banking Mandatory Banking No banking is included in this protocol Genetic Information and Nondiscrimination Act (GINA): Please indicate whether genetic testing is a component of this study This study includes genetic testing and the required GINA language is included in the consent document. This study does not include genetic testing Treatment and Compensation for Injury: Please indicate whether or not the sponsor has a policy to pay for research-related injuries The sponsor does not have a policy to pay for research-related injuries and the appropriate language is included in the consent document. The sponsor does have a policy to pay for research-related injuries and the appropriate language is included in the consent document.