Healthcare Community Research Form

HEALTHCARE COMMUNITY RESEARCH FORM

Study/Project Title:

Principal Investigator / Study Contact

Participant Information

Date of Birth:

Gender: Male Female Non-binary Other

Emergency Contact & Primary Care

Insurance Information

Medical History

Medication Food Environmental No known allergies

Diabetes Hypertension Asthma/COPD Heart disease Cancer

Tobacco use: Yes No Alcohol use: Yes No

Research Participation & Specific Consents

I voluntarily agree to participate in the study described above. I understand the purpose, intended procedures, and anticipated duration of the research. I acknowledge that participation is voluntary and that I may withdraw at any time without penalty or loss of benefits to which I am otherwise entitled.

Potential risks include minimal physical risk for specimen collection, possible discomfort, and a small risk of loss of confidentiality. Benefits may include contributing to knowledge that could improve community health.

I consent to participate in the study procedures described.
I consent to be contacted for follow-up or additional community research activities.
I consent to complete surveys or interviews.
I consent to participate in focus groups or community discussions.
I consent to provide biospecimens (blood, saliva) for the study.
I consent to audio or video recording during study activities.

Collected biospecimens may be processed and stored for the current study. I understand specimens may be retained, coded, and used for future research related to the study objectives unless I indicate otherwise below.

I allow future use of my de-identified biospecimens for related research
I do NOT allow future use; use only for this study

HIPAA Authorization & Release of Medical Records

I authorize my healthcare providers and insurers to disclose protected health information necessary for the purposes of this research to the study team. The information to be disclosed may include medical history, treatment records, laboratory results, medications, and other records relevant to the study. I understand that my information will be used for research and may be combined with information from other participants.

Medical records and clinical notes
Laboratory and imaging results
Billing and insurance information

Authorization Expiration Date:

I understand that I may revoke this authorization at any time by providing a written notice to the study contact listed above, but that revocation will not apply to information already released under this authorization or when the research team has already acted in reliance on this authorization.

Confidentiality & Data Use

Reasonable efforts will be taken to protect the confidentiality of my information. Identifiable information will be kept secure and access limited to authorized study personnel. Data released for publication or sharing will be de-identified whenever feasible. There is, however, no absolute guarantee against unauthorized disclosure.

I agree that de-identified data collected from this research may be shared with other researchers or repositories for secondary analyses related to the study aims.

Acknowledgment

By signing below I certify that I have read and understood the information on this form, I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand that participation is voluntary and that I may withdraw consent at any time.

I acknowledge receipt of information about privacy protections and study procedures.

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