Emory Eye Center Seeks Your Help with IC Vision Study
Online Consent/Information Sheet
For a Research Study
Study Title: Survey to explore the prevalence and risk factors for macular disease in patients with interstitial cystitis (IC)
Principal Investigator: Nieraj Jain, MD, Emory Eye Center
Introduction and Study Overview
Thank you for your interest in our study. We would like to tell you everything you need to think about before you decide whether or not to join the study. It is entirely your choice. If you decide to take part, you can change your mind later on and withdraw from the research study.
The purpose of this study is determine how commonly patients with IC have retina problems, and to identify risk factors for these retina problems. This study will take about 10-15 minutes to complete. If you join, you will be asked to answer questions about your personal characteristics, visual symptoms and eye health history, and past medical and medication history.
The primary risk of this study is a breach of confidentiality. This study is not intended to benefit you directly, but we hope this research will benefit people in the future. Your privacy is very important to us. Your health information that identifies you is your “protected health information” (PHI). No PHI will be collected through the course of this study. To protect your PHI, we will follow federal and state privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA). You may revoke your authorization at any time by calling the Principal Investigator, Nieraj Jain.
If you have questions about this study, your part in it, your rights as a research participant, or if you have questions, concerns or complaints about the research you may contact the following:
Nieraj Jain, Principal Investigator: 404-778-5816
Emory Institutional Review Board: 404-712-0720 or toll-free at 877-503-9797 or by email at email@example.com
Do you have any questions about anything stated above? Were there any parts that seemed unclear?
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