Neurosurgical Research Study Participation Agreement

Study Information

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

Participant Information

Name: ________________________ Date of Birth: _________________ Medical Record Number: ________

Purpose and Procedures

Study Overview

This research study aims to [Insert brief description of study purpose]

Procedures

• Clinical examinations and neurological assessments
• [List specific procedures]
• Follow-up visits scheduled at [intervals]

Risks and Benefits

Potential Risks

• [List potential risks]
• Additional imaging exposure (if applicable)
• Possible complications from procedures

Potential Benefits

• Contribution to neurosurgical knowledge
• [List potential direct benefits]

Participant Rights

• Voluntary participation
• Right to withdraw at any time
• Access to study results
• Privacy protection under HIPAA

Financial Considerations

• Compensation details: [Insert details]
• Cost responsibility: [Specify]

Signatures

Participant Signature: _________________ Date: _______

Witness Signature: ___________________ Date: _______

Investigator Signature: ________________ Date: _______

Contact Information

Principal Investigator: [Phone] Research Coordinator: [Phone] Emergency Contact: [Phone]