Information Sheet for Survey

Principal Investigator: HH Site PI name; list HH Department here

Co-Investigator: Name and credentials here; Location (i.e. College/University)

Title of Study: type name of study here

You are invited to participate in this survey of . I am a graduate/undergraduate student at the , and I am conducting this survey as part of my course work [Remove this statement if it does not apply]. I am interested in finding out .

Your participation in this study will require completion of the attached questionnaire. This should take approximately [X amount] of your time. Your participation will be anonymous and you will not be contacted again in the future. Your participation is completely voluntary. You do not have to answer any question that you do not want to answer for any reason. You will not be paid for being in this study. This survey does not involve any risk to you. However, the benefits of your participation may [list any potential benefits here or change the statement to: This study will provide no direct benefit to you today, but the knowledge that we gain may benefit others in the future]. Your doctor and other medical providers do not have access to any information that you provide me. Your access to and quality of healthcare will not be affected in any way.

Please complete the attached survey and return [Describe method of return here; for example “it to the Research Assistant”, “in the drop box at the receptionists desk”, “self-addressed, pre-paid envelope”]. Thank you.

Who you can call if you have questions about this study:

Questions about: / Contact / Phone #
the research, research-related treatments, or a research related injury / PI Name
Student Researcher’s Name / (860) 545-XXXX
(860) 545-XXXX
your rights as a research participant / An IRB Representative / (860) 545-2893
the research in general / Dr. Laurine Bow, Vice President, Research / (860) 545-2893
a confidential issue that you would like to discuss with someone not associated with research / Patient Relations / (860) 545-1400
Page: / - 1 - / IRB Use Only.
PI:
Account #:
Version: / 10/18/2010