The Ohio State University Consent to Participate in Research
Study Title: A cross-sectional survey of patients with hidradenitis suppurativa
Researcher: Benjamin Kaffenberger
This is a consent form for research participation. It contains important information about this study and what to expect if you decide to participate.
Your participation is voluntary.
Please consider the information carefully. Feel free to ask questions before making your decision whether or not to participate.
Dermatologists at Ohio State University Wexner Medical Center are studying hidradenitis suppurativa and whether certain dietary or environmental changes are helpful.
Completion of a brief survey regarding oral health and modifiable risk factors.
Duration: Approximately 10 minutes
You may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. Your decision will not affect your future relationship with The Ohio State University.
Risks and Benefits:
There are no anticipated risks associated with this study. Potential benefits include the discovery additional recommendations for patients suffering from hidradenitis suppurativa that might alleviate symptom severity.
We will work to make sure that no one sees your survey responses without approval. But, because we are using the Internet, there is a chance that someone could access your online responses without permission. In some cases, this information could be used to identify you.
Also, there may be circumstances where this information must be released. For example, personal information regarding your participation in this study may be disclosed if required by state law. Also, your records may be reviewed by the following groups (as applicable to the research):
· Office for Human Research Protections or other federal, state, or international regulatory agencies;
· The Ohio State University Institutional Review Board or Office of Responsible Research Practices;
· The sponsor, if any, or agency (including the Food and Drug Administration for FDA-regulated research) supporting the study.
Your de-identified information will not be used or shared with other researchers.
There are no financial incentives for participating in this study.
You may refuse to participate in this study without penalty or loss of benefits to which you are otherwise entitled. If you are a student or employee at Ohio State, your decision will not affect your grades or employment status.
If you choose to participate in the study, you may discontinue participation at any time without penalty or loss of benefits. By agreeing to participate, you do not give up any personal legal rights you may have as a participant in this study.
This study has been determined Exempt from IRB review.
Contacts and Questions:
For questions, concerns, or complaints about the study you may contact Paul Macklis or Dr. Benjamin Kaffenberger as outlined above.
For questions about your rights as a participant in this study or to discuss other study-related concerns or complaints with someone who is not part of the research team, you may contact the Office of Responsible Research Practices at 1-800-678-6251 or firstname.lastname@example.org.
I have read (or someone has read to me) this page and I am aware that I am being asked to participate in a research study. I have had the opportunity to ask questions and have had them answered to my satisfaction. I voluntarily agree to participate in this study. I am not giving up any legal rights by agreeing to participate.
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