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How do I fill this out?
To complete this form, please read each section carefully. Make sure to provide accurate information as it pertains to you and your child. If you have any questions, do not hesitate to ask the study staff for clarification.
How to fill out the Informed Consent Form and HIPAA Authorization?
1
Read the entire form thoroughly.
2
Provide the necessary personal and medical information.
3
Sign in the designated area indicating your consent.
4
Submit the completed form as instructed.
5
Keep a copy for your records.
Who needs the Informed Consent Form and HIPAA Authorization?
1
Parents of children suspected of having leukodystrophies.
2
Neurologists requiring informed consent for research.
3
Researchers conducting studies on genetic disorders.
4
Medical staff handling the child's clinical care.
5
Health organizations collecting data for health analysis.
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What are the instructions for submitting this form?
To submit this form, please email it to the designated research coordinator at research@chop.edu. Alternatively, you can fax your completed form to (215) 590-1234. If preferred, you can also submit the form online through our secure portal at www.chop.edu/researchsubmission.
What are the important dates for this form in 2024 and 2025?
The effective date of this consent form is 12/14/2018, with an expiration date of 8/26/2019. Ensure timely submission of your form for research participation eligibility.
What is the purpose of this form?
The purpose of this form is to provide informed consent for participation in the LeukoSEQ research study. By signing this document, you agree to the collection of information and participation in studies related to leukodystrophies. This study aims to enhance the understanding and management of genetic disorders affecting the brain's white matter.
Tell me about this form and its components and fields line-by-line.
- 1. Participant's Name: The full name of the participant who is involved in the study.
- 2. Child's Medical History: Detailed medical history pertaining to the child, including any diagnosed conditions.
- 3. Consent Signature: Signature confirming the consent to participate in the study.
What happens if I fail to submit this form?
If the form is not submitted, your child's eligibility for the study will be impacted. It is essential to provide all required information to facilitate participation in the research.
- Eligibility Risk: Failure to submit may prevent participation in critical research.
- Data Integrity: Incomplete submissions can affect the quality of collected data.
How do I know when to use this form?
- 1. LeukoSEQ Study Enrollment: Use this form to formally consent to participate in the LeukoSEQ research study.
- 2. HIPAA Compliance: This form ensures that personal health information is shared in compliance with HIPAA regulations.
Frequently Asked Questions
How do I fill out this consent form?
To fill out the consent form, read through each section carefully and enter the required information. Make sure to review your responses before signing.
Can I edit this PDF online?
Yes, you can easily edit the PDF online by accessing our editing tools. Modify the text and fields as needed.
What if I have questions while filling out the form?
If you have questions, feel free to contact the study staff for assistance. They are there to help you.
Is my personal information safe?
Yes, your personal information is kept confidential and will only be used for research purposes as outlined in the consent form.
How do I submit the completed form?
You can submit the completed form via email or through our online submission platform.
Will I receive a copy of the consent form?
Yes, you will receive a copy of the signed consent form for your records.
How long will I be involved in the study?
Your participation will involve regular contact for approximately 14 months.
Are there any benefits to participating in this study?
There are no direct benefits, but your participation may contribute to valuable research findings.
Can I withdraw from the study at any time?
Yes, you can withdraw from the study at any point without any penalties.
What happens if I don’t submit the form?
If the form is not submitted, your child's eligibility for the study will be impacted. It is essential to provide all required information to facilitate participation in the research.
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