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Required format:

Consent Form for Future Research

You are being asked to be in this recruitment registry because you expressed interest or have already participated in a healthy participants research study with the Colorado Antiviral Pharmacology Lab (CAVP) at the CU Skaggs School of Pharmacy. If you agree to be included in this registry you will be asked to provide demographic information and contact information.

Using this information, investigators performing COMIRB approved research studies will determine whether you may potentially be eligible for a study. If it is determined that you may be eligible for study participation you will be contacted via phone or email regarding your interest in the study. Emails may include IRB approved study advertisements. Your participation in the registry and any study you are contacted about is completely voluntary. You do not have to participate in any study you don’t want to.

A possible risk of being in this registry is a potential loss of your confidentiality. Every effort will be made to protect your privacy and confidentiality by keeping your information in a secure password-protected database. The University of Colorado Denver (UCD) and its affiliated hospital(s) have rules to protect information about you. Federal and state laws including the Health Insurance Portability and Accountability Act (HIPAA) also protect your privacy.

The institutions involved in this registry include the University of Colorado Denver and the University of Colorado Hospital.

The research registry including your information may be looked at by others who have a legal right to see that information, such as:

Federal offices such as the Food and Drug Administration (FDA), and the Office of Human Research Protections (OHRP) that protects research subjects like you
People at the Colorado Multiple Institutional Review Board (COMIRB)
The study doctor and the rest of the study team (the CAVP Lab)
Officials at the institution where the research is conducted who are in charge of making sure that we follow all of the rules for research

You have a choice about being in this registry. You do not have to be in this registry if you do not want to be. You can withdraw from the registry at any time by contacting a member of the research team.

If you have questions you can call the research team at 303-724-8296, or email us at cricket.nemkov@cuanschutz.edu. You can call or email with questions or concerns at any time.

You may have questions about your rights as someone in this research registry. If you have questions, you can call COMIRB (the responsible institutional review board). Their number is 303-724-1055.

By completing this survey, you are agreeing to be included in the CAVP Healthy Participant Research Registry.

Date Acknowledged:

* must provide value

M-D-Y

Witness Name

* must provide value

Date of Witness:

* must provide value

M-D-Y

For Internal Use:

Consented by:

* must provide value

How was the subject consented?

* must provide value

Phone

Face to face

Consented to be contacted for future research through previous study enrollment.

Remote/electronic

Other

reset

Protocol Consented Under:

* must provide value

Other Consent Details:

* must provide value

Expand

Are you at least 18 years of age?

Yes

reset

Sorry, you are not eligible for our current studies.

Please, check back when you are 18.

First Name

Last Name

Date of Birth

* must provide value

M-D-Y

Age

View equation

Biological sex at birth

Male

Female

reset

Ethnicity

Hispanic or LatinX

Not Hispanic or LatinX

Unknown or Prefer not to say

Race

American Indian or Alaska Native

Hispanic/LatinX

Asian

Native Hawaiian or other Pacific Islander

Black or African American

White

Unknown or Prefer not to say

Other

Other Race

Anything else you you'd like us to know?

Expand

Contact Information: Please provide at least one way we can get in touch

Phone 1

Is it OK for us to leave a voicemail?

Yes

reset

Phone Type 1

Cell

Home

Work

Other

reset

Phone 2

Is it OK for us to leave a voicemail?

Yes

reset

Phone Type 2

Cell

Home

Work

Other

reset

Email 1

Email 2

Preferred method of contact

Phone

reset

How did you hear about us?

Participated in previous study

Study Flyer

CU Listserv

ClinicalTrials.gov

Other

If Flyer, where:

AMC Campus

UCD Campus

Other

reset

Flyer Location, other

Please, specify

Thanks for joining our Research Registry!
Remember you can contact us at anytime to be removed from this list or to update your contact information.

Cricket.Nemkov@cuanschutz.edu
Kayla.Campbell@cuanschutz.edu

303.724.8296

For Office Personnel only

Office Notes:

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Contacted

No Interest

Not Eligib

Interested

Screened

Enrolled

Complete

W/D

DOT-DBS (6419)

Cell Prep (1812)

SIM/DTG-DTI

TAF-DBS

A-Team

Subject Requesting Removal from registry

Yes

Removal by Study Staff

reset

Withdrawal Date:

M-D-Y

Withdrawal reason if known

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If subject requests to be removed from registry, please remove all information from their record EXCEPT the RECORD ID.

Please edit their record ID to show "WD" preceding the ID number. ex. WD12345

You have selected an option that triggers this survey to end right now.

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.