ÐÏࡱá>þÿ Z\þÿÿÿYÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥ÁÀ ø¿ "bjbj1²1² 8FSØSØ¥gÿÿÿÿÿÿ·Ê Ê $$$$$ÿÿÿÿ8888plÜ$84â@@(hhhœ"¾Ò —3™3™3™3™3™3™3$ú5²¬8r½3$ÞœœÞÞ½3$$hh4Ò3ÞR$h$h—3Þ—3ª§.|0hÿÿÿÿð%·X6]Ñÿÿÿÿ0R#/ƒ3è3045/ê9‚Ø9$09$0dÞÞÞÞÞÞÞ½3½3ZºÞÞÞ4ÞÞÞÞÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ9ÞÞÞÞÞÞÞÞÞÊ ê: Future Contact Script Template v. 2/01/2016 The information highlighted in yellow is guidance. DELETE THIS AND ALL OTHER HIGHLIGHTED INSTRUCTIONS BEFORE SUBMITTING. This script template may be utilized for obtaining verbal consent for participation in a database used for future contact for research. If the document will be used as an Information Sheet, utilize the Information Sheet template (see  HYPERLINK "http://www.rochester.edu/ohsp/rsrb/docTemplates/consentFormTemplates.html" RSRB Consent Template website). RSRB Requirements: Use of “Subject”: The script must use the term research “subject” rather than “participant” or “volunteer”. Use of 2nd Person: The script must be written in the 2nd person (e.g., “You are being asked to take part in a research study about…”). Pagination: Maintain page numbering already inserted in the footer (e.g., “2 of 4”). Version Date: Manually type the date in the footer rather than selecting “Insert Date” from the toolbar to avoid automatic updates each time the document is opened. Margins: Maintain the bottom margin of at least 2 inches to provide space for watermarking upon approval. Sample Language: Sample language for certain procedures and risks is provided in the  HYPERLINK "http://www.rochester.edu/ohsp/rsrb/docTemplates/consentFormTemplates.html" Consent Document Sample Language guide. VERBAL SCRIPT Database for Future Contact [Insert Title of Study] Hi, my name is [state your name]. I’m working with [insert PI name] from the University of Rochester’s Department of [insert department] on a research database (a list) of individuals who are interested in taking part in future research studies. Do you have a few minutes to discuss participation in this database? If yes, continue below. If no, but the potential subject is interested in participating, determine a better time to call back to discuss the study. If no, thank them for their time. The [doctors/researchers] in the [Insert Department/Center/Group] at the University of Rochester have created a database (a list) of individuals who are interested in taking part in future research studies about [insert population/disease/condition]. People included in the database will be contacted when a new study starts to see if they are interested in participating. If you decide to be included in the database, your contact information [and information from your medical and research records (if applicable)] will be placed in this database. If applicable: This will include information such as [insert database variables – e.g., name, date of birth and diagnosis]. Researchers may then contact you in the future about new research on [insert population/disease/condition]. If you are contacted, you can decide at that time whether or not you are interested in participating in the study. Being included in the database does not mean you will be automatically enrolled in the study; you are only agreeing to be contacted about future research studies. You may change your mind and have your name, and any additional information that was collected, removed from the database at any time by contacting the study team using the information below. There will be no cost to you to participate in this database. You will not be paid for participating in this database. Does this sound like something you’d be willing to participate in? If yes, continue below. If no, thank them for their time. Before you agree to participate, there are some additional things you should know about the study. Participation in research may involve some loss of confidentiality. None of your information will be used for research without your permission. Your contact information will not be shared with anyone outside the study team. [If an alteration of HIPAA Authorization is being requested for research activities collecting protected health information (PHI), the altered HIPAA language provided in the two paragraphs below may be used.] In order to collect information for the database, we have to get your permission to use and give out your personal health information.  We will use [list all information that may be used/disclosed as indicated in the protocol for purposes of the database, e.g., contact information, related information from your medical records, etc.] to conduct the study.  Your permission to use your health information for this database will not expire unless you tell us you want to cancel it.  We will keep the information we collect about you indefinitely. [Note to Investigators: if you plan to remove subjects from the database at a definite time point that should be stated instead, e.g., After 3 years, you will automatically be removed from the database and no longer contacted.] Your participation in this database is completely voluntary. You are free not to participate or to withdraw at any time, for whatever reason. No matter what decision you make, there will be no penalty or loss of benefit to which you are entitled. Additional student-subject wording [delete if not applicable]: Participating in this database will not affect your class standing or grades at the University of Rochester. You will not be offered or receive any special consideration if you take part in this database. Additional employee-subject wording [delete if not applicable]: Taking part in this database is not a part of your University duties, and refusing will not affect your job. You will not be offered or receive any special job-related consideration if you take part in this database. ** If possible, signature blocks should appear all on one page. Do you have any questions? Do you agree to participate in this database?  FORMCHECKBOX  Yes: Document oral consent below. If applicable, inform subject that they will receive an information sheet regarding the study for their records via [mail/email].  FORMCHECKBOX  No: Thank them for their time. Name of Subject: ____________________________________________________ Person Obtaining Consent I have read this form to the subject. An explanation of the research was given and questions from the subject were solicited and answered to the subject’s satisfaction. In my judgment, the subject has demonstrated comprehension of the information. The subject has provided oral consent to participate in this research database. 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