Welcome to the Cornea Research Foundation Fuchs' dystrophy Survey. Completion of the study should take approximately 10 to 20 minutes. Please complete the questions to the best of your knowledge. Thank you!
PURPOSE AND CONSENT
DESCRIPTION: Participation by invitation only in a 10-20 minute research study to find out how Fuchs’ dystrophy has impacted your life as well as your treatment path. You may sign this consent electronically and complete the survey that follows it, or you may sign the consent and complete the survey on paper and mail them back to the Sponsor.
PAYMENT: No compensation will be provided as a result of participating in this survey.
ALTERNATIVE: Not to participate in this research study.
POTENTIAL RISKS: The only risk is a possible breach of confidentiality.
BENEFITS: This study will gather patient perceptions of Fuchs’ dystrophy at various stages of treatment. You will receive an emailed copy of the collective results.
SPONSOR/CONTACT: Cornea Research Foundation of America
9002 N. Meridian St., Suite 212, Indianapolis, IN 46260, Phone: 317-814-2996
PRINCIPAL INVESTIGATORS: Francis W. Price, Jr., M.D. & Matthew T. Feng, M.D.,
CONFIDENTIALITY: Dr. Francis Price, Dr. Matthew Feng, the Cornea Research Foundation of America, and the Institutional Review Board (IRBCo, Inc.) that provided study approval may view or make a copy of your signed consent and surveys. Efforts will be made by all medical personnel and third parties to protect the confidentiality and security of your personal health information during and after the study. However, absolute confidentiality cannot be guaranteed because of the need to give information to these parties. Collective study results will be shared with participants and may be published for scientific purposes but your identity will not be revealed. The completed surveys and signed consents will be kept in secure, password-protected electronic files.
This consent form and study have been approved by the Institutional Review Board (IRB). The IRB is a group of scientific and non-scientific committee members who review and approve or disapprove research involving people by following the federal rules. This group is also required by the FDA to do periodic review of ongoing research studies. Questions, comments or complaints about your rights as a volunteer may be addressed to:
IRB Company, Inc. Phone: 1-877-680-4138
E-Mail:
irb@irbco.com Website:
www.irbco.comVOLUNTARY PARTICIPATION/WITHDRAWAL: Your participation in this study is voluntary. You may decide not to participate or withdraw from the study at any time without affecting your future medical care at this site.
By signing your name, email address and date you consent: I have read and understand this consent form. I have been given an opportunity to ask questions and get answers concerning my participation. I authorize the release of my medical records and health information as relates to this study, including my signed consent form, to the sponsor, IRB and other regulatory agencies as described above. I freely consent to participate in this research study and understand that I may print a signed copy of this consent and authorization for my records.
By signing this consent form I have not waived any of my legal rights, which I otherwise would have as a subject in a research study.
