ADULT CONSENT FORM

Time Customs and Sleep in American Indian Shift Workers

Your PHI will be used only for the purpose(s) described in the section “What is the Purpose of this Study?”

Your PHI will be shared, as necessary with the Institutional Review Board (IRB) and with any person or agency required by law. You are also allowing the research team to share your PHI with other people or groups specified below. All these persons or groups are obliged to protect your PHI.
No other groups are involved

You are authorizing us to use and disclose your PHI for as long as the research study is being conducted. By signing this authorization, you are temporarily waiving your right to see research related information while the study is going on. You will be able to see this information if you wish after the research is completed.

You may revoke this authorization to use and share your PHI at any time by contacting the principal investigator in writing. If you revoke this authorization, you may no longer participate in this research. If you revoke this authorization, use and sharing of future PHI will be stopped. The PHI that has already been collected may still be used.

The only persons who will have access to your research records are the study personnel, the Institutional Review Board (IRB), and any other agency required by law. The results of this study will not be included in your medical record. Any information obtained during this study which could identify you will be kept strictly confidential. The information from this study may be published in scientific journals or presented at scientific meetings, but your identity will be kept strictly confidential.

WHAT ARE YOUR RIGHTS AS A RESEARCH PARTICIPANT?

You have rights as a research participant. These rights are explained in The Rights of Research Participants which you have been given. If you have any questions concerning your rights, you may contact the Institutional Review Board (IRB), telephone (402) 559-6463.

WHAT WILL HAPPEN IF YOU DECIDE NOT TO PARTICIPATE?

You can decide not to participate in this study or you can withdraw from this study at any time. Your decision will not affect your care or your relationship with the investigator(s), the University of Nebraska Medical Center, the Nebraska Health System (NHS) hospitals, or the University of Nebraska at Omaha. Your decision will not result in any loss of benefits to which you are entitled.

If any new information develops during the course of this study that may affect your willingness to continue participating, you will be informed immediately.