Clinical Trial Research Participation Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

Study Details

Protocol Number: _______________ Principal Investigator: __________ Study Title: ___________________

Participation Agreement

1. Voluntary Participation

I understand that my participation in this oncology research study is entirely voluntary. I may withdraw at any time without affecting my current or future medical care.

2. Study Procedures

I acknowledge that I have been informed about and understand:

• The purpose of the research study
• The experimental procedures and treatments involved
• The duration of my participation
• The potential risks and benefits
• Alternative treatment options

3. Confidentiality

I understand that:

• My medical information will be kept confidential
• Study data will be coded to protect my identity
• Access to my records is limited to authorized research personnel

4. Costs and Compensation

• Study-related procedures: □ Covered □ Not covered
• Standard care procedures: □ Covered □ Not covered
• Travel compensation: □ Yes □ No

5. Contact Information

Principal Investigator: _____________ Phone: _________________________ Emergency Contact: ______________

Signatures

Patient Signature: ________________ Date: ________

Investigator Signature: ____________ Date: ________

Witness Signature: _______________ Date: ________