Thank you for your interest in participating in our study!
The Building Empowerment and Resilience Therapeutic Program for Women with Trauma (BEAR Study)Please read through the brief descriptions of our BEAR study. This will walk you through the procedures that are involved so that you will have a complete understanding of the timeline. When you have finished reading the description, please continue to the online consent below. Acknowledgment of reading the study description does not obligate you to participate. This consent is only obtaining your permission to gather some basic health information. This basic information will assist us in determining eligibility for our study. You must be at least 18 years of age to complete our online screening process.
The survey will collect some basic demographic, medical, and psychiatric history, as well as assess current mood.
After completion of the survey, we will contact you to inform you of your eligibility.
We look forward to discussing your eligibility shortly.
STUDY SCREENING CONSENT FORM For this initial screening, with your permission, we would like to collect health information about you, including information about your general health (current mood states, family history, general medical conditions, medications, therapy, height, weight, etc.) related to medical treatments and care you receive.
RISKS AND BENEFITSThere are no anticipated risks associated with this screening. You will not receive any direct benefit from participation. We cannot and do not guarantee or promise that you will receive any benefits from this screening.
TIME INVOLVEMENTYour participation in this survey is self-timed, and usually takes anywhere from 10-20 minutes. Soon after completion (usually 1-2 weeks) we will contact you regarding your eligibility.
PAYMENTSYou will not be paid to complete this survey.
PARTICIPANT'S RIGHTSIf you have read this form and have decided to participate in this survey, please understand your participation is voluntary and you have the right to withdraw your consent or discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled.
The results of this screening may be presented at scientific or professional meetings or published in scientific journals. However, your identity will not be disclosed. You have the right to refuse to answer particular questions.
AUTHORIZATION TO USE YOUR HEALTH INFORMATION FOR RESEARCH PURPOSES
Because information about you and your health is personal and private, the information you provide us in this survey generally cannot be used in this research study without your agreement.
If you read through this consent and continue onto the survey, it will provide that authorization. The form is intended to inform you about how your health information will be used or disclosed in the study.
Your information will only be used in accordance with this authorization form and the informed consent form and as required or allowed by law. Please read it carefully before moving onto the survey.
Please keep a copy of this consent for your records.
What is the purpose of this survey and how will my health information be utilized in the study?The purpose of this survey is to collect data to determine eligibility for participating in our research study. The data you provide us will not only help determine your eligibility for this study, but it will assist us in learning about individuals who decide to participate or not in this type of research, and it will be very valuable in planning future studies.
Do I have to agree to this authorization form?No. Agreeing to this authorization form is voluntary.
You may choose to stop answering these survey questions at any time.
If I agree to this consent, can I revoke my agreement or withdraw from the research later? Yes.
If you decide to participate, you are free to withdraw your authorization regarding the use and disclosure of your health information (and to discontinue any other participation in the survey) at any time.
After any revocation, your health information will no longer be used or disclosed in the study, except to the extent that the law allows us to continue using your information (e.g., necessary to maintain integrity of research).
If you wish to revoke your authorization for the research use or disclosure of your health information in this study, you must write to:
Dr. Jennifer Keller at 401 Quarry Road, MC 5719, Stanford, CA, 94304 for removal from the BEAR Therapeutic Group study.
What Personal Information Will Be Used or Disclosed?All medical and other data provided by you will be coded with an identification number and your name and other identifying information will be removed.
Who May Use or Disclose the Information?The following parties are authorized to use and/or disclose your health information in connection with this research study:
Protocol Directors
The Stanford University Administrative Panel on Human Subjects in Medical Research and any other unit of Stanford University as necessary
Research Staff
When will my authorization expire?Your authorization for the use and/or disclosure of your health information will end on January 1, 2030 or when the research project ends, whichever is earlier.
CONTACT INFORMATION Questions, Concerns, or Complaints: If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, or alternative courses of treatment, you should ask Dr. Jennifer Keller, (650) 724-0070. You should also contact her at any time if you feel you have been hurt by being part of this study. Independent Contact: If you are not satisfied with how this study is being conducted, or if you have any concerns, complaints, or general questions about the research or your rights as a participant, please contact the Stanford Institutional Review Board (IRB) to speak to someone independent of the research team at (650)-723-5244 or toll free at 1-866-680-2906.
You can also write to the Stanford IRB, Stanford University, 1705 El Camino Real, Palo Alto, CA 94306