Heart-2-Heart Consent for Web-Based Eligibility Screen
Thank you for your interest in the Heart-2-Heart Study. Before filling out the eligibility questions, please read the consent form below and click on the "I Agree" button at the bottom of the page if you understand the statements and freely consent to providing personal information to see if you may be eligible for this research study.
Participation in this online eligibility screen will take about 5 minutes. In this eligibility screen, we will ask you for your first and last name, phone number, e-mail address, date of birth, city, and state of residency. As well as questions about your relationship status, questions about your romantic partner, and if there has been a recent suicide related event.
All responses are treated as confidential. Be aware that confidentiality will be maintained to the extent possible. There is always the risk of compromising privacy, confidentiality and/or anonymity when using the internet. There is the possible risk of feeling uncomfortable about answering a question. You do not need to answer any question that you do not want to answer. This study is supported by NIH, and study information may be reviewed by NIH representatives. Authorized representatives from the University of Pittsburgh Office of Research Protections may review your data solely for the purpose of monitoring the conduct of this study.
Participation is voluntary. Refusal to fill out the eligibility screen will have no effect on your current or future relationship with the University of Pittsburgh, or your current or future medical care at a UPMC hospital or affiliated health care provider, or your current or future relationship with a health care insurance provider.
If you have further questions or concerns about your rights as a participant in this eligibility screen or any questions about your rights as a research subject, contact the Human Subjects Protection Advocate at the University of Pittsburgh IRB Office, University of Pittsburgh (1-866-212-2668). If you have questions concerning the study, contact the study investigator: Stephanie Stepp, Ph.D. (412) 383-5051, or by email at steppsd@upmc.edu. You may also contact the Administration Program Coordinator, Jennifer Wilson at pghgirlsstudy@upmc.edu.
You may print a copy of this form. If you understand the statements above, and freely consent to participate in the eligibility screen for the Heart-2-Heart Research Study click on the "I Agree" button to begin the assessment.
Consent Form
To verify if you and your partner may be eligible to participate in the Heart-2-Heart Research Study we are asking you to complete this online eligibility screen.Participation in this online eligibility screen will take about 5 minutes. In this eligibility screen, we will ask you for your first and last name, phone number, e-mail address, date of birth, city, and state of residency. As well as questions about your relationship status, questions about your romantic partner, and if there has been a recent suicide related event.
All responses are treated as confidential. Be aware that confidentiality will be maintained to the extent possible. There is always the risk of compromising privacy, confidentiality and/or anonymity when using the internet. There is the possible risk of feeling uncomfortable about answering a question. You do not need to answer any question that you do not want to answer. This study is supported by NIH, and study information may be reviewed by NIH representatives. Authorized representatives from the University of Pittsburgh Office of Research Protections may review your data solely for the purpose of monitoring the conduct of this study.
Participation is voluntary. Refusal to fill out the eligibility screen will have no effect on your current or future relationship with the University of Pittsburgh, or your current or future medical care at a UPMC hospital or affiliated health care provider, or your current or future relationship with a health care insurance provider.
If you have further questions or concerns about your rights as a participant in this eligibility screen or any questions about your rights as a research subject, contact the Human Subjects Protection Advocate at the University of Pittsburgh IRB Office, University of Pittsburgh (1-866-212-2668). If you have questions concerning the study, contact the study investigator: Stephanie Stepp, Ph.D. (412) 383-5051, or by email at steppsd@upmc.edu. You may also contact the Administration Program Coordinator, Jennifer Wilson at pghgirlsstudy@upmc.edu.
You may print a copy of this form. If you understand the statements above, and freely consent to participate in the eligibility screen for the Heart-2-Heart Research Study click on the "I Agree" button to begin the assessment.