Cardiac Surgery Research Study Participation Agreement

Study Information

Study Title: [Insert Study Title] Principal Investigator: [Insert Name], MD Institution: [Insert Institution Name] IRB Protocol Number: [Insert Number]

Participant Information

Name: _____________________________ Date of Birth: ______________________ Medical Record Number: _____________

Purpose and Procedures

I understand that I am being asked to participate in a research study involving cardiac surgery. By signing this document, I acknowledge:

• The purpose of this study is to [Insert specific study purpose]
• My participation will involve the following procedures:
  • [List specific procedures]
  • Collection of medical data
  • Follow-up visits as scheduled
• The estimated duration of my participation is [Insert timeframe]

Risks and Benefits

Potential Risks

• [List specific risks]
• Additional procedures beyond standard cardiac surgery
• Possible privacy risks related to data collection

Potential Benefits

• [List potential benefits]
• Contribution to medical knowledge
• Possible improvements in cardiac surgical procedures

Rights and Confidentiality

1. Participation is voluntary
2. Right to withdraw at any time
3. Medical care will not be affected by decision
4. Data protection measures in place

Signatures

Participant Signature: _________________ Date: _______

Investigator Signature: ________________ Date: _______

Witness Signature: ___________________ Date: _______

Contact Information

Principal Investigator: [Phone] Research Coordinator: [Phone] IRB Office: [Phone]