医学患者授权同意伦理证明模板.doc

IRB Use Only Approval Date: Monthname dd, 20yy Expiration Date: Monthname dd, 20yy STANFORD UNIVERSITY Research Consent FormProtocol Director:Protocol Title:  Form: SUSampCons-dc rev 06/12  PAGE 4 of  NUMPAGES 4 SAMPLE CONSENT FORM For Prospective Collection of Medical Information/Data DESCRIPTION: You are invited to participate in a research study on diabetes. From the information collected and studied in this project we hope to learn more about diabetes, including factors that may affect the development and progression of this condition. PROCEDURES: With your permission, we would like to collect health information about you, including information about your general health (height, weight, blood pressure, results from blood tests, medications, physical exam results) related to medical treatments and care you receive. We would like to collect this information about you after each medical visit you have for as long as you are treated at a Stanford Clinic or hospital. This study does not involve any treatment; just the collection and study of medical information. RISKS AND BENEFITS: There are no anticipated risks associated with this study. You will not receive any direct benefit from participation. We cannot and do not guarantee or promise that you will receive any benefits from this study. TIME INVOLVEMENT: Your participation in this study will not require more time from you other than for the initial visit where this study is explained to you. If you agree to participate, we will collect your medical information from your medical record after each visit, which does not involve any direct participation by you. PAYMENTS: You will not be paid to participate in this study. PARTICIPANT’S RIGHTS: If you have read this form and have decided to participate in this project, please understand your participation is voluntary and you have the right to withdraw your consent or discontinue