Research Participation Agreement - Family Medicine

Purpose

This agreement outlines the terms and conditions for participation in clinical research studies conducted at [PRACTICE NAME].

Participant Information

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

Agreement Terms

1. Voluntary Participation

• I understand that my participation in any research study is entirely voluntary
• I may withdraw from the study at any time without affecting my regular medical care
• My decision to participate or not will not impact my relationship with my healthcare providers

2. Rights and Responsibilities

Participant Rights:

• Receive complete information about the study's purpose, procedures, and potential risks
• Ask questions at any time during the study period
• Access my personal health information collected during the study
• Receive prompt medical attention for any study-related injuries

Participant Responsibilities:

• Provide accurate medical history and current health information
• Follow study protocols as explained by the research team
• Report any adverse effects or concerns promptly
• Attend scheduled study visits and procedures

3. Confidentiality

• All personal health information will be protected according to HIPAA regulations
• Data will be coded and stored securely
• Results may be published without identifying participants

4. Compensation and Costs

• Study-related medical care will be provided at [specify terms]
• Compensation for participation: [specify amount/terms if applicable]
• Responsibility for standard medical care costs remains with the participant

Signatures

Participant Signature: ________________________ Date: __________

Witness Signature: __________________________ Date: __________

Principal Investigator: _______________________ Date: __________

Contact Information

Study Coordinator: [NAME] Phone: [NUMBER] Email: [EMAIL]

IRB Contact: [CONTACT INFORMATION]