ONLINE SCREENING QUESTIONNAIRE
WAIVER OF DOCUMENTATION
The following information applies to the adult participant or to the child or ward. If the participant is a child or ward, the use of "you" refers to "your child" or "your ward".
DESCRIPTION: Thank you for your interest in participating in a diabetes-related research study. The purpose of this screening questionnaire is to create a clinical research registry from which investigators within the Stanford Diabetes Research Center can recruit participants. In order to find out whether you are eligible for particular studies, you will be asked to complete a pre-screening questionnaire. There are two steps involved in this pre-screening process: 1) consent to be screened via the questionnaire, and 2) if you agree to the consent, complete the online screening questionnaire to determine whether you are eligible to attend an in-person screening visit with one or more groups part of the Stanford Diabetes Research Center in the near or distant future. Your information will be kept as confidential as possible as required by law. This survey is encrypted for additional security.
TIME INVOLVEMENT: Your participation will take approximately 10 minutes to complete the questionnaire.
RISKS AND BENEFITS: There are no foreseeable risks associated with this pre-screening survey. You may benefit by becoming eligible for one or more diabetes-related studies conducted at Stanford University. We cannot and do not guarantee or promise that you will receive any benefits from this study.
CERTIFICATE OF CONFIDENTIALITY: This research is covered by a Certificate of Confidentiality from the National Institutes of Health. The researchers with this Certificate may not disclose or use information, documents, or biospecimens that may identify you in any federal, state, or local civil, criminal, administrative, legislative, or other action, suit, or proceeding, or be used as evidence, for example, if there is a court subpoena, unless you have consented for this use. Information, documents, or biospecimens protected by this Certificate cannot be disclosed to anyone else who is not connected with the research except, if there is a federal, state, or local law that requires disclosure (such as to report child abuse or communicable diseases but not for federal, state, or local civil, criminal, administrative, legislative, or other proceedings, see below); if you have consented to the disclosure, including for your medical treatment; or if it is used for other scientific research, as allowed by federal regulations protecting research subjects.
The Certificate cannot be used to refuse a request for information from personnel of the United States federal or state government agency sponsoring the project that is needed for auditing or program evaluation by the NIH which is funding this project or for information that must be disclosed in order to meet the requirements of the federal Food and Drug Administration (FDA). You should understand that a Certificate of Confidentiality does not prevent you from voluntarily releasing information about yourself or your involvement in this research. If you want your research information released to an insurer, medical care provider, or any other person not connected with the research, you must provide consent to allow the researchers to release it.
PAYMENTS: You will not receive 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. With your permission, your identity will be made known to research groups within the Stanford Diabetes Research Center for recruitment purposes only. 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.
CONTACT INFORMATION:
Questions: If you have any questions, concerns or complaints about this research, its procedures, risks and benefits, contact the Protocol Director, Christopher Gardner, PhD at (650) 725-2751.
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, 3000 El Camino Real, Five Palo Alto Square, 4th Floor, Palo Alto, CA 94306.
Please print a copy of this page for your records