top

Consent Form (Sample)

This is a preview of the study consent form. If you choose to participate in the study, we will ask you to sign this consent form before continuing.

Title of Study: Online Education and Support for Alzheimer’s Caregivers — Summative Evaluation
Principal Investigator: Meghan B. Coulehan, MPH
Phone number: 919-960-8118
Co-Investigators: T. Bradley Tanner, MD
Sponsor: National Institute on Aging, National Institutes of Health
Grant #: R43AG026227

This research study is being conducted by Meghan B Coulehan, MPH, of Clinical Tools, Inc. to assess the value, strengths and weakness of the Dementia Care Central website. Your feedback will help up develop and improve the website.

The First Step

At the start of the study you will be asked to answer a series of questions about your knowledge of dementia and your mood and feelings of burden about caregiving. Then we will ask you to visit the Dementia Care Central website at least once a week for four (4) weeks. We will send you reminder emails once a week. We also ask that you post a message to the website forums once a week — instructions on how to do so are on the website. After 4 weeks have passed we will ask you to answer the same series of questions again, plus some new questions about your satisfaction with the website.

If the answers to any of the questions on mood or caregiver burden indicate you should talk a physician about your own health, we will email you more information about the topic and contacting your doctor. We do not and can not provide any health care or individual medical advice.

Benefits & Risks

The risks are that answering the questions may make you uncomfortable or tired. You can stop at any point and discontinue the study. The benefits are that we will learn more about how caregivers feel and what online tools can help them.

Compensation

You will be compensated $25 at the conclusion of the study to acknowledge that we appreciate your time and effort. There is an optional 4 week follow -up where we will ask you again to complete the same sets of question. Compensation to acknowledge your help for that activity is $25.

There is no cost to you to participate in this study.

Confidentiality

All your information will be kept confidential, except what you choose to share voluntarily on the forums, which will be visible to others who are also using the Forums. We will not share your name or email address with anyone.

Voluntary Participation

Your participation in this research is voluntary. You may discontinue participation at any time during the research activity.

Contact Us

You can ask questions at any time (even after the study ends) – contact Meghan Coulehan (coulehan@clinicaltools.com) or 919-960-8118. If you have questions about your right as a research participant, please contact the co-chair of the Human Subjects Research Committee at Clinical Tools, Susan Wilhelm, PhD. at wilhelm@clinicaltools.com

Now you can close this window and await further instructions via email. Thanks!