Source | hl7.fhir.us.sirb#current:Single Institutional Review Board (sIRB) Implementation Guide (v4.0.1) |
resourceType | Questionnaire |
id | sirb-consent-questionnaire-populate |
canonical | http://hl7.org/fhir/us/sirb/Questionnaire/sirb-consent-questionnaire-populate |
version | 1.0.0 |
status | draft |
publisher | HL7 International - BR&R Work Group |
name | Consent_Questionnaire |
title | Consent Questionnaire |
date | 2023-03-29T06:17:19+00:00 |
jurisdictions | us |
Usages | (none) |
Research Study
Study Title
Short Title of the Research Study
IRB Protocol Number
Study Site
Select the relying site that this consent form pertains to, in order to pre-populate the relying institution and relying site principal investigator details below.
This question and its answer will not print on the Consent Form but are necessary for the form logic. If you do not want pre-population to occur, leave this question blank and manually fill in the relying institution and relying site principal investigator details.
Is this relying site also functioning as the lead site for the overall study with the lead PI for the overall study as the site PI? *
This question and its answer will not print on the Consent Form but are necessary for the form logic.
Study Site Principal Investigator and Study Site
Multi-site statement
Statement for Consent Form at Lead PI Site
Statement for Consent Form at Relying Site (not Lead PI Site)
Principal Investigator at Study Site
First Name
First or given name of the relying site PI
Last Name
Surname or family name of the relying site PI
Suffix
Suffix such as Junior (Jr.), Senior (Sr.), I, II, III, IV, etc.
Degree(s)
Professional and Academic degrees of the relying site PI
Associated Institution
Relying site PI's Academic or Professional Institution
Contact Information
Phone
10-digit phone number, including area code
Information on how to contact the Site PI.
Principal Investigator at Relying Site conducting the study, responsible for the conduct of the study at the relying site
Study Site Institution
Institution Name
Public or private entity conducting the study- where the participant will go or call
Address
Street Address
City
State
Zip Code
Country
Information about institution for the site where study will be conducted
Lead Principal Investigator and Lead Principal Investigator Site
Statement about Lead PI and Lead PI Site for Consent Form at Relying Site
Lead Principal Investigator
First Name
First or given name of the lead PI
Last Name
Surname or family name of the lead PI
Suffix
Suffix such as Junior (Jr.), Senior (Sr.), I, II, III, IV, etc.
Degree(s)
Professional and Academic degrees of the lead PI
Contact Information
Phone
10-digit phone number, including area code
Information on how to contact the Lead PI.
Person(s) designated as the lead PI(s) for the multisite clinical trial; has the appropriate level of authority and responsibility to direct the research being conducted at all sites participating in the clinical trial.
Lead Principal Investigator Institution
Name
Public or private entity associated with the lead principal investigator conducting the overall study.
Address
Street Address
City
State
Zip Code
Country
Information about Lead Institution
Sponsor or Funding Source
Sponsor Name
Entity financially supporting the research
Sponsor Detail
Any additional relevant information about the sponsor(s)
Is this consent an eConsent?
Consent that is obtained electronically
Summary Text
Summary Text Statement *
Describes the basic purpose, procedures and reasons behind the research in easily understood prose
Section header for the mandated text describing the basic purpose, procedures and reasons for the study.
Introduction and Statement of Research
About Consent Form
Introductory Paragraph to the participant. Includes statement of research and explanation of the consent process.
Purpose
Reason for Research
Explanation about why the study is being conducted
Interactions with others
Statement of whom the participant can anticipate interacting with during study participation
Invited Participants
High level information about what participating in the study will entail for the participant
Total expected study enrollment
The total number of people targeted for enrollment in the multi-site study
Additional Enrollment Text
Additional field for including miscellaneous enrollment information. May include information about total enrollment from the relying site
What is involved in the study?
High level information about what participating in the study will entail for the participant.
Assessments
Assessment List
Name of the Assessment
Short name of the assessment
Description of Assessment
Short description of the assessment
Assessment Supplemental Text
Additional text to provide additional context about the assessments collected
Do you want to upload the "Assessment List" table instead of typing the assessments directly into this questionnaire?
If you upload a table, it must be in .csv format or .xlsx format and it must have the same columns in the same order as in the "Assessment List" table in the questionnaire.
Assessment List Attachment(s)
Describe the file that is being attached (optional)
Upload attachment(s) here.
Visits and Procedures
Visit Introductory Text
Introductory Text to include prior to the visit table to introduce what the tables contain and explain any additional detail or information about the visit schedule.
Visit List
Visit Type
Unique visit type, defined by the procedures which are completed within that visit. E.g. Screening, Baseline, Followup, Final
Visit Description
Description of Visit types, including what procedures it contains
Visit Duration
Visit Duration Units
Choices for visit duration units are minutes (min), hours (h) or days (d).
Number of Visits
Do you want to upload the "Visit List" table instead of typing the visits directly into this questionnaire?
If you upload a table, it must be in .csv format or .xlsx format and it must have the same columns in the same order as in the "Visit List" table in the questionnaire.
Visit List Attachment(s)
Describe the file that is being attached (optional)
Upload attachment(s) here.
Procedure List
Name of Procedure
Common Term of Procedure
Description of a Procedure
Experimental Procedure Indicator
Research Indicator
Frequency
Specify the procedure frequency and the applicable frequency units. For example, 4 times per year or 2 times per week.
Procedure Duration (minutes)
Specify the procedure duration in minutes
Procedure Supplemental Text
Additional Text to include after the procedure table to provide the participant with any additional information needed about procedure schedule
Do you want to upload the "Procedure List" table instead of typing the procedures directly into this questionnaire?
If you upload a table, it must be in .csv format or .xlsx format and it must have the same columns in the same order as in the "Procedure List" table in the questionnaire.
Procedure List Attachment(s)
Describe the file that is being attached (optional)
Upload attachment(s) here.
Total Duration of Study Participation
Time elapsed for a participant to be part of the study from initial enrollment to final discharge or completion
Risks
Risk List
Name of the risk
Description of Risk
Risk Category
Do you want to upload the "Risk List" table instead of typing the risks directly into this questionnaire?
If you upload a table, it must be in .csv format or .xlsx format and it must have the same columns in the same order as in the "Risk List" table in the questionnaire.
Risk List Attachment(s)
Describe the file that is being attached (optional)
Upload attachment(s) here.
Risk Supplemental Text
Additional text for description of other risks
Fetal Risks
Indicates whether risks to the fetus are possible
Fetal Risk Details
Textual description of risks to the fetus
Alternative Procedures
Alternative Procedure Text
Describe any other treatment/procedure that may be used other than those described for study participation.
Benefits
Benefits List
Name of Benefit
Description of Benefit
Benefit to you
Benefit to society
Do you want to upload the "Benefits List" table instead of typing the benefits directly into this questionnaire?
If you upload a table, it must be in .csv format or .xlsx format and it must have the same columns in the same order as in the "Procedure List" table in the questionnaire.
Benefits List Attachment(s)
Describe the file that is being attached (optional)
Upload attachment(s) here.
Compensation
Will there be compensation for participation?
Indicates whether compensation will be offered or not for the study
Compensation Supplemental Text
Additional text about compensation not captured in the compensation table
Compensation List
What types of visits or milestones will I be compensated for?
How many visits or milestones of this type will there be compensation for?
How much will be paid per that type of visit?
Do you want to upload the "Compensation List" table instead of typing the risks directly into this questionnaire?
If you upload a table, it must be in .csv format or .xlsx format and it must have the same columns in the same order as in the "Compensation List" table in the questionnaire.
Compensation List Attachment(s)
Describe the file that is being attached (optional)
Upload attachment(s) here.
Costs
What are the costs of participation, if any?
Explanation informing participant if any additional costs will occur to the participant as a result of taking part in the study
Will there be reimbursement for other study visit costs incurred?
Reimbursement to participant for other study visit costs not directly associated with a visit
Will costs be covered for medical treatment if research related injury occurs?
Indicates if participant or the participant's insurance will be responsible for any injury which occurs or if the sponsor will cover any treatment costs for injury
Additional description of treatment coverage
Description of other costs not directly associated with a visit
Participant Rights and whom to contact for answers
What are the rights of a participant?
Statement of particpant rights
Site IRB Contact Information
IRB Contact Name
IRB Name
Department Name or Division
Street Address
City
State
Zip Code
Country
Phone
10-digit phone number, including area code
Contact information for the site IRB contact.
Study Coordinator Contact Information
Study Coordinator Name
Study Coordinator Institution or Organization
Department Name or Division
Street Address
City
State
Zip Code
Country
Phone
10-digit phone number, including area code
Contact information for the study coordinator
Site Principal Investigator Contact Information
Site Principal Investigator Name
Site Principal Investigator Institution
Department Name or Division
Street Address
City
State
Zip Code
Country
Phone
10-digit phone number, including area code
Contact information for the PI. May be replicated from above.
Participation
Voluntary Permission Statement
Standard prepopulated statement, can be edited.
What are the anticipated circumstances under which participant's participation may be terminated by the investigator without regard to the participant's or the legally authorized representative's consent.
Anticipated circumstances under which subject's participation may be terminated by investigator without regard to subject's or legally authorized representative's consent
Early Withdrawal
Are there consequences to participant for early withdrawal?
Are there Emotional Consequences of Withdrawal
Are there Physical Consequences of Withdrawal
What are the consequences of withdrawal?
Description of the withdrawal consequences, will depend and vary based on type of study.
Confidentiality of Records
Will HIPAA content be included within this document?
Medical information and billing statement
If template information required for your state differs from text provided, reword to satisfy state requirements.
Will confidentiality be protected?
Indicates if records identifying a subject will be maintained.
How will confidentiality be protected?
Explanation about processes and procedures to support maintaining privacy and confidentiality
Are there data security or policies that need to be included in the consent, particularly around device use (optional)
Indicates if any data security policy applies to this consent, including device use.
Describe any data security policies and processes protecting the data
Optional field for capturing information on IT related data security policies. Example, use of encryption when utilizing mobile data collection
Who can use or see participant information?
Role or group who will have access to data
Description of Information Disclosed
Will the data be released for future use?
Indicates whether these data will be used beyond the study window
Will the future use data be deidentified?
Indicates if shared data will retain any identifiers.
Deidentification detail
Description of deidentification details for future use datasets.
Required text disclosure surrounding future use.
Select the appropriate required text statement about disclosure surrounding future use of participant's data from the two standardized statements.
Specimen Management
Were specimens collected as part of this study?
Is whole genome sequencing being conducted?
Indicator of if genome sequencing is being conducted in conjunction with study
Sharing or no Sharing of samples.
Indicator of whether biospecimens will be shared outside of the immediate study team or institution.
Conditions of sharing
Textual description of sharing conditions including, type, when, etc.
Will participant share in profit with commerical use?
Indicator of any plans to profit share any funds received as a result of commercial use of those samples.
Description of Collection and Storage
Textual description of collection and storage procedures and policies for the study.
Can consent for sample use be revoked?
Indicator of revocation of sample consent is an option
Will there be Broad Consent for Storage, maintenance and secondary research use?
Statement of Broad Consent for Storage, maintenance and secondary research use
Can the study team contact you for future research?
Conditions about contact for additional sample use, information not currently described or future research
Description of the details for which the participant could be contacted
Indicator if the participant contact information can be used for future questions or recuitment for this or other studies
Will participants share in commercial profit?
Details about any profit sharing agreements or why profits will not be shared.
Indicator of participants will receive any commercial profits resulting from their participation in study
Will the study team contact you with new information that may affect your willingness to remain in the study
Indicator if study team will provide updates that may affect willingness to remain in study
Will the study team disclose clinically relevant study results to you?
Condtions under which the study results will be disclosed to you
Textual description of which results and when will be disclosed to you.
Indicator of study team will provide results of lab tests or other feedback of results to you at any time.
Clinical Trials.gov statement
Is this study covered under a Certificate of Confidentiality? (default Y in NIH)
Certificate of Confidentiality Statement
Indicator if study is covered under a certificate of confidentiality (automatially issued for NIH studies)
Required Disclosures based on state law
Add any required text per your state laws.
When will the PHI Authorization Expire based on date or time past an event
PHI authorization expiration. Might be never, a certain date, or a period after a study milestone, such as 6 months after study closure.
Statement of PHI Authorization Revocation
Signature
Indicator to include Participant Signature and Date/Time
Indicator to include Assent Signature and Date/Time
Indicator to include Legally Authorized Representative Signature and Date/Time
Relationship of Legally Authorized Representative
Indicator to include a Witness Signature and Date/Time
Indicator to include Parent 1 Signature and Date/Time
Indicator to include Parent 2 Signature and Date/Time
Consent Version
Consent Version Number
sIRB Version Date of Consent
Date that changes whenever a change is made to the consent. It is the versioning system of the sIRB institution, and is updated in accordance with the institution's policy.
Relying Site Version Date of Consent
A number that changes whenever a change is made to the consent. It is the versioning system of the relying institution, and is updated in accordance with the institution's policy.
Expiration Date of Consent
Other Attachments
Describe the file that is being attached (optional)
Attachment
Other attachments that will be included in the Consent Form that will be provided to the participants should be included here.
Questionnaire Response ID for the parent Questionnaire Response (such as the Initiate a Study Questionnaire Response), if any
ID of the Research Study FHIR Resource associated with the study Questionnaire Responses, if any
Produced 06 Apr 2023