Research Participation Agreement - Internal Medicine

Study Information

Study Title: [INSERT STUDY NAME] Principal Investigator: [INSERT NAME], MD Study ID: [INSERT NUMBER]

Participant Information

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

Agreement Terms

1. Voluntary Participation

I understand that my participation in this research study is entirely voluntary. I may refuse to participate or withdraw from the study at any time without penalty or loss of benefits to which I am otherwise entitled.

2. Study Procedures

• I agree to participate in the following procedures: [LIST PROCEDURES]
• Duration of participation: [INSERT TIME PERIOD]
• Number of visits required: [INSERT NUMBER]

3. Risks and Benefits

• Potential Risks: [DETAIL RISKS]
• Expected Benefits: [DETAIL BENEFITS]
• Alternative Treatments: [LIST ALTERNATIVES]

4. Confidentiality

I understand that my medical information will be kept confidential as required by law. My identity will not be revealed in any publication or presentation of research results.

5. Costs and Compensation

• Study-related costs covered: [LIST COVERED COSTS]
• Participant compensation: [INSERT COMPENSATION DETAILS]

6. Contact Information

For questions about:

• Research procedures: [STUDY COORDINATOR CONTACT]
• Rights as a research subject: [IRB CONTACT]
• Medical emergencies: [EMERGENCY CONTACT]

Signatures

Participant Signature: _________________ Date: _______

Investigator Signature: ________________ Date: _______

Witness Signature: ___________________ Date: _______