Consent Form: " Gerontology Center Participant Registry"

Consent Form: "Gerontology Center Participant Registry"

The Gerontology Center at CU at CU Colorado Springs is actively seeking adults to participate in research studies. To that end, we are collecting names to form a Participant Registry.

This Database contains names of individuals that have expressed an interest in gender, year of birth, race, phone number, and mailing address. You may decide not provide all of this information. In that case you can still be added to the database.

University faculty members affiliated with the CU Gerentology Center have access to this Database. CU students working as research assistants for the faculty members will also this database. CU students working as research assistants for these faculty members will also have access to the database. The faculty members or their research assistants will contact you and invite you to participate in studies. You are free to decline any invitation to participate in a study. You may request to have your name removed from the Database at any time. In some cases you may be financially compenstated for your participation.

Your identity will be confidential. All participant information in the Database is kept in a locked filing cabinet and a password protected computer file. The database will not be used for any reason other than recruiting research participants. The database will not be given to anyone outside of the Gerentology Center.

If you have questions regarding this database, you may contact the principal investigator, Michael Kisley (719) 255-4177. If you have questions regarding your rights as a research participant or any concerns regarding your rights as a research participant or any concerns regarding this database, you may report them confidentially if you wish -- to Sandy Wurtele, Chairperson of the CU Colorado Institutional Review Board. (719) 255-4150.


*Do you agree to the information above?

Please complete any or all of the following items:

*Date:
*Name:
*Gender:
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*Your Year of Birth:
*Phone
*Address:
*Please specify your race:
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Validation Code
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* denotes required field