Stanford University Neurosciences Patient Registry for Clinical Trials - Active Version

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Thank you for showing interest in Stanford University Neurosciences clinical trials. Please fill out all information to the best of your knowledge.

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Please read the information below carefully.

The purpose of this survey is to collect information on patients that are interested in participating in clinical trials conducted by the Stanford University Medical Center Departments of Neurosurgery and Neurology.

The information you provide to us in the following pages will be kept in a secure database for our researchers and their clinical teams to use when recruiting for certain research studies. All information will be kept as confidential as possible as required by law.

By filling out the following survey, you are not guaranteed to be considered for a clinical trial related to your or a relative's condition. However, if you or your relative appear to be a potential candidate for a current or upcoming research study, you will be contacted by the clinical research team.

We cannot and do not guarantee or promise that you will receive any benefits our research studies.

Your decision whether or not to participate in this survey will not affect your medical care.

You should not feel obligated to answer every question that follows. You may stop and return to the survey at any time if you are uncertain about some of the questions that you are being asked. The more information you are able to provide to us, the better our ability will be to consider you for a clinical trial.

You will not be paid for answering any questions in this survey.

If you have any questions, concerns, or complaints about this survey, contact neuro.stanford.team@gmail.com. If you want to talk to someone separate from the research team about a concern or complaint or your rights as a possible research subject, please contact the Stanford Institutional Review Board (IRB) to speak to an informed person who is separate from the research team, at 650-723-5244, or toll-free at 1-866-680-2906. In addition, please call the Stanford IRB at these numbers if you cannot reach the research team.

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.

Have you carefully read the above information?

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You must read all of the information above before proceeding with the registry.

Do you understand the above information?

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Yes

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It is important that you understand the above information. Please re-read it, and if you have further questions, you may contact ____.

You may download the text on the current and following pages by clicking the item below. Please feel free to take as much time as you need to decide whether or not to participate in our patient registry.

Attachment:Patient Registry Information for Patients.docx

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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.