I have been invited to participate in a research study titled: This study is being carried out by, who may be reached at:
I realize that my participation is entirely voluntary, and that I may refuse to participate or withdraw at any moment without explanation or punishment. In addition, I have the right to request that any information belonging to me or my participation be returned, removed, or destroyed.
I believe that the study's goal is to look both patient-level and systemic/institutional-level elements that contribute to emergency department overcrowding. I understand that if I volunteer to take part in this study, I will be asked to:
Share my views of the factors contributing to ER overcrowding
BENEFITS
I understand that the benefits I may gain from participation include:
Offering expert opinion that can play a transformative role in addressing the strain in the ED and contributing to the robustness of stock of knowledge to shape evidence-based intervention
RISKS
I understand that the risks, discomforts, or stresses I may face during participation include:
The views shared may only be of important in academic endeavors and may not be of any help in shaping future policies
CONFIDENTIALITY
I understand that the only people who will know that I am a research subject are members of the research team. No individually-identifiable information about me, or provided by me during the study will be shared with others except when necessary to protect the rights and welfare of myself and others (for example, if I am injured and need emergency care, if the provided information concerns suicide, homicide, or child abuse, or if revealing the information is required by law).
FURTHER QUESTIONS
I understand that any further questions that I have, now or during the course of the study can be directed to the researcher ( ).
Additionally, I understand that questions or problems regarding my rights as a research participant can be addressed to Dr. Jessica Hillyer, Institutional Review Board Director of Compliance and Training, South University, 7700 W. Parmer Ln., Austin, TX 78729;
[email protected]; 512-516-8779.
My signature below indicates that the researchers have satisfactorily answered all of my current questions about this study and that I understand the purpose, procedures, benefits, and risks described above. I have also been offered a copy of this form to keep for my own records.
Participant Printed Name
Signature of Participant Date (mm/dd/yyyy)
Signature of Principal Investigator Date (mm/dd/yyyy)
