ࡱ> ceba -bjbjzz 8RP\P\%g DDDDDXXX8t$X)9(>(fff8888888$ ;=|8D5558DDff48!!!5FDfDf8!58!!\35f m{F3880)94=>=>(5=>D5,h!TM88)95555=> > : [INSERT ELECTRONIC DEPARTMENT LETTERHEAD ON PAGE 1 IF A PAPER COPY WILL BE PROVIDED TO SUBJECTS] Information Sheet (Survey) Template v. 2/07/2017 The information highlighted in yellow is guidance. DELETE THIS AND ALL OTHER HIGHLIGHTED INSTRUCTIONS BEFORE SUBMITTING. RSRB Requirements: Use of Subject: The information sheet must use the term research subject rather than participant or volunteer. Use of 2nd Person: The information sheet 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. INFORMATION SHEET [Insert Title of Study] Principal Investigator: [Insert] This form describes a research study that is being conducted by [insert name of Principal Investigator/Faculty Advisor and Co-Investigator (if applicable)] from the University of Rochesters Department of [insert department or school name]. The purpose of this study is to Describe the general purpose of the study and include relevant background information. If possible, limit the explanation to why study is being done to one or two sentences (e.g., "learn more about how men and women communicate pleasant and unpleasant feelings). If you decide to take part in this study, you will be asked to complete X surveys that will take about X minutes to complete. The surveys will ask questions aboutProvide a short description of the content of the surveys. For example, If you decide to take part in this study, you will be asked to complete 2 surveys that will take about 10 minute to complete. The surveys will ask questions about your memory, concentration and eating habits. We estimate that approximately [insert number of subjects] will take part in this study. If communication by email between study team and subject is intended (i.e., sending and receiving email), indicate in this section. [Insert risks as described in the protocol such as the examples provided here.] Some of the survey questions may be upsetting or make you feel uncomfortable. You can skip any of the questions you do not want to answer. If applicable, modify accordingly: Because this study involves collecting personal, identifiable information about you, there is a potential for invasion of privacy or breach in confidentiality. To minimize this risk, we will not store any directly identifiable information about you with your survey responses. All of the information we collect will be stored in a secure manner and only study team members will have access to it. There are no other expected risks [or insert a description of any other additional physical, psychological, social, legal and economic risks/discomforts]. There are also no expected benefits. (If applicable for use of email) Transmitting your information by e-mail has a number of risks that you should consider. These include, but are not limited to, the following: E-mail can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. E-mail senders can easily misaddress an e-mail. Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy. Employers and on-line services have a right to inspect e-mail transmitted through their systems. E-mail can be intercepted, altered, forwarded, or used without authorization or detection. E-mail can be used to introduce viruses into computer systems. If applicable, insert a discussion regarding any appropriate alternative procedures or options that might be advantageous to the subject (e.g., not participating or alternative options). If applicable: The Ĵý is receiving payment from [insert sponsor name] for conducting this research study. If the study is not funded by an external agency (i.e., department funds) this statement may be deleted. If the Principal Investigator or any other study personnel has a conflict of interest management plan involving the study sponsor and the plan requires disclosure of the conflict, insert the disclosure statement here. You will not be paid for participating in this study. [Alternately, You will receive XX credit of participating in this study or You will be paid $XX for participating in this study.] There will be no cost to you to participate in this study [or, if there are costs to the subject, provide a description of these costs]. The Ĵý makes every effort to keep the information collected from you private. In order to do so, we will [insert protection measures]. Sometimes, however, researchers need to share information that may identify you with people that work for the University [regulators or the study sponsor]. If this does happen we will take precautions to protect the information you have provided. [As applicable to an identifiable data set - Results of the research may be presented at meetings or in publications, but your name will not be used.] Conditions for the Use of E-mail (If applicable) The researcher cannot guarantee but will use reasonable means to maintain security and confidentiality of e-mail information sent and received. You and researcher must consent to the following conditions: E-mail is not appropriate for urgent or emergency situations. The researcher cannot guarantee that any particular e-mail will be read and responded to. E-mail must be concise. You should schedule an appointment if the issue is too complex or sensitive to discuss via e-mail. E-mail communications between you and the researcher will be filed in your research record. Your messages may also be delegated to any member of the study team for response. The researcher will not forward subject-identifiable e-mails outside of URMC and Affiliates without your prior written consent, except as authorized or required by law. You should not use e-mail for communication regarding sensitive medical information. It is your responsibility to follow up and/or schedule an appointment if warranted. E-Mail Instructions (If applicable) Avoid use of your employers computer. Put your name in the body of the e-mail. Put the topic (e.g., study question) in the subject line. Inform the researcher of changes in your e-mail address. Take precautions to preserve the confidentiality of e-mail. Contact the researchers office via conventional communication methods (phone, fax, etc.) if you do not receive a reply within a reasonable period of time. [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 study information, 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 e.g., your research record, related information from your medical records, and both clinical and research observations made while you take part in the research, screening logs, case report forms, survey forms, questionnaires, etc.] to conduct the study. Your permission to use your health information for this study 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 destroy the records at a definite point that should be stated instead.] If you cancel your permission, you will be removed from the study. Your participation in this study 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 benefits to which you are otherwise entitled. Additional student-subject wording [delete if not applicable]: Participating in this study 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 research. Additional employee-subject wording [delete if not applicable]: Taking part in this research 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 research. For more information or questions about this research you may call [insert Principal Investigator or other contact persons name] at [telephone number]. Please contact the University of Rochester Research Subjects Review Board at 265 Crittenden Blvd., CU 420628, Rochester, NY 14642, Telephone (585) 276-0005 or (877) 449-4441 [insert country code (001) if applicable] for the following reasons: You wish to talk to someone other than the research staff about your rights as a research subject; To voice concerns about the research; To provide input concerning the research process; In the event the study staff could not be reached.     RSRB Case Number: 000XXXX Page  PAGE 4 of  NUMPAGES 4 Version Date: xx/xx/20xx 26B_`b}}iS=S=S=S* *hWlRh;56B*OJQJ^Jph* *hWlRhs56B*OJQJ^Jph'hm< hWlR56B* OJQJ^Jph* *hm< hm< 56B* OJQJ^Jph* *hm< hH<56B* OJQJ^Jph* *hm< hWlR56B* OJQJ^JphhMHB*OJQJ^Jph *hMHB*OJQJ^Jph *hWlRB*OJQJ^Jph$ *hhMHB*OJQJ^Jphab  ! , ) k l ~  gd; $1$a$gd>1 & Fgd; & FgdWlRgdWlR$a$gd;$a$gdWlR$a$gdMH  7 H , A  ) 2 ѽ}gPggg=g=$ *hk+J56B*OJQJ^Jph- *hWlRh;56B*H*OJQJ^Jph* *hWlRh;56B*OJQJ^Jph- *hihi56B*H*OJQJ^Jph$ *hi56B*OJQJ^Jph* *h;hWlR56B*OJQJ^Jph' *h;56;B*OJQJ^Jph- *hWlRhs56;B*OJQJ^Jph- *hWlRhc56;B*OJQJ^Jph2 ; > Y a @ A B b c i j k l }  waK@2hhZ5OJQJ^Jh85OJQJ^J* *hh;5;B*OJQJ^Jph* *hWlRh;56B*OJQJ^Jph% *h;hk+J0J56OJQJ^J9j *h;hk+J56B*OJQJU^Jph3j *h;hk+J56B*OJQJU^Jph* *h;hk+J56B*OJQJ^Jph$ *hk+J56B*OJQJ^Jph* *hWlRh;R56B*OJQJ^Jph   ƵƔugZMZ?1 *hhd6OJQJ^J *hhQfOJQJ^JhhenOJQJ^JhhQOJQJ^JhhZ5OJQJ^J'hh h B*OJQJ^Jph *h OJQJ^J *h^hh OJQJ^J$hhZ5B*OJQJ^Jph!hh>1B*OJQJ^Jph!hhZB*OJQJ^Jph' *h hZ5B*OJQJ^Jph' *h h 5B*OJQJ^Jph ! 1 2 U V n w %˾񤱏ugTgGhhIOJQJ^J$ *hQhenB*OJQJ^Jph *hQhenOJQJ^JhRhenOJQJ^JhhT8,OJQJ^Jh*6OJQJ^J *h7COJQJ^JhhenOJQJ^JhhQOJQJ^JhhCwOJQJ^JhhQfOJQJ^J *hhd6OJQJ^J *h1JOJQJ^J *hhenOJQJ^J"#$+ABx~f࿱{k{XK>0 *hhIOJQJ^JhhT8,OJQJ^JhhIOJQJ^J$ *hTIhTIB*OJQJ^Jph *h3B*OJQJ^Jph *hB*OJQJ^Jph$ *hTIh(bB*OJQJ^Jph$ *h?2Gh?2GB*OJQJ^Jphh?2GB*OJQJ^Jphh(bB*OJQJ^Jph$ *hlhhlhB*OJQJ^JphhlhB*OJQJ^Jph!hhIB*OJQJ^Jph9]x{|}XZ[}ֵ֗~s~i\RH: *hHhHOJQJ^Jht4OJQJ^JhOJQJ^Jh3h3OJQJ^JhGOJQJ^J *hGOJQJ^J *hGhGOJQJ^J *hH<OJQJ^JhhIOJQJ^J! *hm< B*OJQJ]^Jph' *hSVhm< B*OJQJ]^JphhhTOJQJ^JhhT8,OJQJ^J *hhIOJQJ^J *hhT8,OJQJ^J|}"DABPQ & Fgdm< $a$gd; & Fgdm< gdm< gd*6gd;}?16>Qd>ȺȆ{m`UG9G *hhOJQJ^J *hhpfOJQJ^J *hm< OJQJ^JhRhm< OJQJ^J *h hhm< OJQJ^J *h*6OJQJ^JhhT8,OJQJ^J *hOJQJ^J *hh<'OJQJ^J *ht4h<'OJQJ^J *ht4hOJQJ^JhOJQJ^Jht4hOJQJ^JhtkOJQJ^Jht4ht4OJQJ^JhHOJQJ^J>-<=>?JL}r}e[eMB4 *hh(OJQJ^J *h+5OJQJ^J *hl9h~OJQJ^Jh6OJQJ^Jhh(OJQJ^J *h. OJQJ^J *hhYz<OJQJ^J *hhp7OJQJ^Jhhp7OJQJ^J *hh2OJQJ^Jhh2OJQJ^JhIlOJQJ^J *hIlhIlOJQJ^J *h*6OJQJ^JhhpfOJQJ^J *hhOJQJ^JLKLOPQhiµtgYgOgE7g *hsFChsFCOJQJ^JhsFCOJQJ^JhcOOJQJ^J *hhY OJQJ^JhhY OJQJ^Jhh hOJQJ^Jhh(OJQJ^J *hl9OJQJ^J *hhOJQJ^J *hl9hl9OJQJ^JhhOJQJ^J *h~OJQJ^J *h6OJQJ^J *hh(OJQJ^J *hhOJQJ^J *h+5OJQJ^J~!!!""U#W##$'$µ~qgq~qgq\NCN *hOJQJ^J *h?hOJQJ^Jhm< 5OJQJ^Jhm< OJQJ^Jh hhm< OJQJ^J *h hhm< OJQJ^J *hm< OJQJ^J$ *h hhm< 56>*OJQJ^Jh*65OJQJ^JhhT8,OJQJ^JhsFCOJQJ^J *hsFCh_t:OJQJ^J *hsFCOJQJ^J *hsFChsFCOJQJ^Jhh$OJQJ^JD B!!!!! "E"~""V#W#($%&l'm'o(q(gd_t:gdH$a$gdgd$a$gd;$a$gdm<  & Fgdm< gdm<  & Fgdm< '$O$c$m$u$$$%&.&&''<'F'k'm''''''',(G(H(Z(d(o(p(q(ylaY *hh)hhCw^JaJhhqvbOJQJ^Jh!k|OJQJ^JhIlOJQJ^JhhnOJQJ^JhhCwOJQJ^Jhh*65OJQJ^Jh*65OJQJ^JhhCw5OJQJ^JhF5OJQJ^J *hgIhOJQJ\^JhgIhOJQJ^JhOJQJ^Jq(((|)})****+ +2+3+5+H+~++++++++++ , ,--ƹ}}s}}eZeZeKhQfhn^JaJnHtH *hX_OJQJ^J *hhX_OJQJ^JhH<OJQJ^JhhX_OJQJ^JhX_OJQJ^Jh7JOJQJ^J *hh7JOJQJ^Jhh7JOJQJ^JhhCwOJQJ^Jhh)OJQJ^J *hh)5OJQJ^J *hh OJQJ^J *hh)OJQJ^Jq(|)})**(,,,,------ -!-#-$-y-}-~---gdw1gd; & F @ 88^8gdX_gdX_gd h1$gd)-------!-"-$-)-*-.-/-9-=-C-D-J-K-L-M-Q-R-\-]-^-_-n-t-v-x-y-~---ظأأأأظظ،hP%hm< CJOJQJ^JaJmHnHu)jh]2hPCJOJQJU^JaJ# *h]2hPCJOJQJ^JaJhPCJOJQJ^JaJ h]2hPCJOJQJ^JaJhKjhKUhQfhn^JaJ#6&P1h:pH</ =!"#$@ % DyK yK http://www.rochester.edu/ohsp/rsrb/docTemplates/consentFormTemplates.htmlyX;H,]ą'cs2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List L/L Nonie)56CJOJQJ\]^JaJo(ph3fL^L Normal (Web)dd[$\$ B*phP/P head11+57>*CJOJQJS*Y(\aJo(phfH"H .X Balloon TextCJOJQJ^JaJ424 |Header  !4 @B4 |Footer  !>P@R> T8, Body Text 2 OJQJaJB' aB "dComment ReferenceCJaJ<r< "d Comment TextCJaJ:: "dComment Text Char@jqr@ "dComment Subject5\F/F "dComment Subject Char5\6U`6 *6 Hyperlink >*B*phFV F SFollowedHyperlink >*B* phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] %R fffi2   }>L'$q(-- !"#%&(q(-$'Ab%X+249DFi!@ @H 0(  0(  B S  ? IgJgKgLgMgNgOg PgQgRg``nUUc!!!% jww_ll !!!% 9 *urn:schemas-microsoft-com:office:smarttagsplace>*urn:schemas-microsoft-com:office:smarttags PersonName=*urn:schemas-microsoft-com:office:smarttags PlaceName= *urn:schemas-microsoft-com:office:smarttags PlaceType    %%%%% %!%#%$%~%%%%%%% %!%#%$%~%% ,Aoo(jllx | W W X 6 b d h~lmm"5#####$$%%%%%%%%%%% %!%#%$%C%M%Q%_%y%~%% ,Aoo(jllx | } }   h~lmm"5#####$$$$$$%%%%%%%%%%%% %!%#%$%~%% 8\8Fw%(. 5F%.-v~6ErzOK0_p$"W_yyhh^h`)88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.h hh^h`hH)88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.h ^`hH.h pp^p`hH.h @ L@ ^@ `LhH.h ^`hH.h ^`hH.h L^`LhH.h ^`hH.h PP^P`hH.h  L ^ `LhH. @ @ ^@ `CJOJQJo(hH ^`OJQJ^Jo(hHo pp^p`OJQJo(hH @ @ ^@ `OJQJo(hH ^`OJQJ^Jo(hHo ^`OJQJo(hH ^`OJQJo(hH ^`OJQJ^Jo(hHo PP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh hh^h`hH)88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.OK5F%_pv~6E_yy w%                           SL                                   ])is]2-%EY Y m< #u  ;MH!)6l9>aCw3+5tY00t4]; t =!!e'!r"d_#!'<'>)N+8,U.].0´0>11a4*65678:;H<Yz<X?DSBsFC 9E?2GFGTIk+J1JEMNP;RWlRSSXVSo\U+ W.XjYnYX_:a#b(bqvbcGc"dydQfXf^fpf hlhtkenGjn@p-rrr[uRvr^wIxk3zDz|oD|T|!k|~D}3T+(s@8SaPUHa!` ?_|zPUP$#,8=s]3P"uKX"'sw#znH&[G~R,8H7Q> N3,`z~&W8e |r: Q1w~p7Il$G. ()0<Gh< .kd67C2BKLTi~ILD(Zc\@FZ[QHd,Wtb 17JcO#Z\ N%%@\\\\%@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7. [ @Verdana5. .[`)Tahoma?= *Cx Courier New;WingdingsA$BCambria Math"h B'R'3CCqr4%% 3qHP?~2!xx Telephone Consent exampleOHRE Flagg, Emily(       Oh+'0  8 D P \hpxTelephone Consent exampleOHRENormalFlagg, Emily4Microsoft Office Word@Ik@,@$@%7]@R՜.+,D՜.+,< px  version 15-Mar-05Univ of NC at Chapel HillC% Telephone Consent example Title 8@ _PID_HLINKSA[CJhttp://www.rochester.edu/ohsp/rsrb/docTemplates/consentFormTemplates.html  !"#$%&'()+,-./013456789:;<=>?@ABCDEFGHIJKLMNOPQSTUVWXY[\]^_`adRoot Entry FDnfData *1Table2e>WordDocument8RSummaryInformation(RDocumentSummaryInformation8ZCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q