The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

e6WBJqdcxqd5HSEzkRivfmoVk5GpPT5YFxCLjdB

Participant Information

Please complete the survey below.

Thank you!

Study Name: PanLab Research Registry

Research Information Sheet

DESCRIPTION: You are invited to participate in a research study on creating a research registry of potential participants for studies at the PanLab at Stanford University under Protocol Director Dr. Leanne Williams. Her work is focused on developing a model for understanding mental disorders at a neural circuit level and using this model for targeting therapeutic approaches. This registry will serve to record your information and reach out if we are currently recruiting for any research studies that might be a good fit for you. You will be asked to provide general contact information and details about your current psychiatric symptoms, past treatments and current medications. To participate in this study you will first complete a quick online eligibility screen. If eligible, you will fill out an online survey collecting the information detailed above.

TIME INVOLVEMENT: Your participation will take approximately 30 minutes.

RISKS AND BENEFITS: The risks associated with this study are a potential breach of confidentialy of the information you provide.The benefits which may reasonably be expected to result from this study are being contacted in the future for studies within our lab that might be a good fit for you. We cannot and do not guarantee or promise that you will receive any benefits from this study. Your decision whether or not to participate in this study will not affect your ability to participate in other research studies or seek medical care. If you are an employee at Stanford, your employment at the university will not be negatively impacted. If you are a student at Stanford, withdrawal from this study will not adversely affect your academic performance

PAYMENTS: You will receive no compensation as payment for your participation.

PARTICIPANT'S RIGHTS: If you have read this form and have decided to participate in this project, 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 alternative is not to participate. You have the right to refuse to answer particular questions. The results of this research study may be presented at scientific or professional meetings or published in scientific journals. Your individual privacy will be maintained in all published and written data resulting from the study.

Identifiers might be removed from identifiable private information and, after such removal, the information could be used for future research studies or distributed to another investigator for future research studies without additional informed consent from you.

Authorization To Use Your Health Information For Research Purposes

Because information about you and your health is personal and private, it generally cannot be used in this research study without your authorization. If you agree to this form, 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 agreeing to it.

What is the purpose of this research study and how will my health information be utilized in the study?
The purpose of this study is to create a registry of potential research participations for current and future studies within the PanLab at Stanford University. Your health information will be used to determine whether you might be a good candidate for one of our studies.

Do I have to agree to this authorization form?
You do not have to agree to this authorization form. But if you do not, you will not be able to participate in this research study. Agreeing to the form is not a condition for receiving any medical care outside the study.

If I agree, can I revoke it or withdraw from the research later?
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 study) 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. Leanne Williams at leawilliams@stanford.edu.

What Personal Information Will Be Obtained, Used or Disclosed?
Your health information related to this study, may be used or disclosed in connection with this research study, including, but not limited to your name, address, age, email address, phone number, and information regarding current and past psychiatric illness.

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:
• The Protocol Director Dr. Leanne Williams
• The Stanford University Administrative Panel on Human Subjects in Medical Research and any other unit of Stanford University as necessary
• Research Staff

Who May Receive or Use the Information?
The parties listed in the preceding paragraph may disclose your health information to the following persons and organizations for their use in connection with this research study:

• The Office for Human Research Protections in the U.S. Department of Health and Human Services

Your information may be re-disclosed by the recipients described above, if they are not required by law to protect the privacy of the information.

When will my authorization expire?
Your authorization for the use and/or disclosure of your health information will end on December 31, 2050 or when the research project ends, whichever is earlier.

CONTACT INFORMATION:
Questions: If you have any questions, concerns or complaints about this research, its procedures, risks and benefits, contact the Protocol Director, Dr. Leanne Williams at (650) 723-3579.

You should also contact them at any time if you feel you have been hurt by being a 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.

Please print a copy of this page for your records.

If you agree to participate in this research, please complete the attached questionnaire.

Are you currently between the ages of 18 and 69 years old?

* must provide value

Yes

reset

Are you completing this form for someone else?

* must provide value

Yes

reset

Name

* must provide value

Preferred Name

DOB

* must provide value

D-M-Y

Age

* must provide value

Are you able to commute to Stanford, California for potential study visits?

* must provide value

Yes

Maybe

reset

Preferred Method of Contact?

* must provide value

Phone Call

E-Mail

Text Message

* must provide value

Phone number

Is it okay to leave voicemails at this number?

Yes

reset

Do you have a history of depression or other mental health related illness?

* must provide value

Yes

reset

In the past month, have you experienced any symptoms of depression, anxiety, or other mental health challenges?

Yes

reset

How did you hear about this study?

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.