Sie sind auf Seite 1von 2

CONSENT TO PARTICIPATE IN RESEARCH

PROJECT TITLE: Changing practice: Screening diabetic patients for vitamin B12 deficiency

INVESTIGATOR: Natalie Patrick-Brown, ARPN, FPN-BC


Wilkes University DNP student
natalie.patrickbrown@live.wilkes.edu
(352) 650-2799

Faculty Chair: Dr. Corinne Coppinger


Corinne.Coppinger@wilkes.edu

You are being asked to participate in a research study, Changing practice: Screening diabetic patients for vitamin
B12 deficiency. This form is design to provide you with information about the study and to answer your questions.
If you decide to participate, you will be asked to sign this form and it will a record of your agreement to participate.
You will be given a copy of this form to keep.

Purpose: The research project is to assess the between education and screening diabetic patients for
vitamin B12 deficiencies. Will education of healthcare providers make a difference?

Procedure: If you agree to be in this study, you will be asked to complete a survey review the attached education
and complete a post educational survey. You will be de-identified during research study. You will be assigned a
numeric number that will be maintained by the primary investigators. No identifying information will be used during
the study. the survey will take approximately 30 minutes to complete.

There is no risk, nor any benefit to the participants and your participation is voluntary. Your decision not to
participate or to withdraw from the study will involve no penalty or loss of benefits to which you are otherwise
entitled.

Confidentiality: Reasonable efforts will be made to keep the personal information in your research record private
and confidential. Any identifiable information obtained in connection with this study will remain confidential and
will be disclosed only with your permission or as required by law.

Your name will not be used in any written reports or publications which result from this research. Data will be kept
for three years (per federal regulations) after the study is complete and then destroyed.

Payment: You will not be paid for your participation in this study.

Participation is Voluntary: If you consent to be a volunteer in this research project concerning the importance of
screening diabetic patients for vitamin B12 deficiencies. You are free to withdraw your consent and discontinue
participation at any time without prejudice to you. You should also understand that the investigator has the right to
withdraw you from the research project at any time. An example would be the failure of the volunteer to follow
instructions given to them by the investigator.

Questions: If you have any questions concerning your participation in this study, now or in the future, contact
Natalie Patrick-Brown, ARPN, FPN-BC @ natalie.patrickbrown@live.wilkes.edu or (352) 650-2799.

If you have questions about your rights as a research participant, you may contact Wilkes University Institutional
Review Board (IRB), which is concerned with the protection of volunteers in research projects. You may reach the
board office between 8:00 AM and 5:00 PM, Monday through Friday, by calling (570) 408-4565 or (570) 408-7387.
You may also email Wilkes University IRB at irb@wilkes.edu

Documentation of Consent: By signing below, you indicate that you have read, or had read to you, all the above
information about this research study, including possible risks and the likelihood of any benefits to you. The content
and meaning of this information has been explained, and is understood. All your questions have been answered.
You hereby consent and voluntarily offer to follow the study requirements and take part in this study. You will
receive a signed copy of this consent form.

Name (print): _______________________________________ Date: ____________

Consenting signature: _________________________________ Phone: ___________

Investigator's signature: _______________________________ Date: ____________

Das könnte Ihnen auch gefallen