Center for Imaging Research

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Consent to Fill Out the Enrollment Form

Please read the information below before filling out the enrollment form.

Thank you for your interest in this Institutional Review Board-approved study, Neuroimaging of Anesthetic Modulation of Human Consciousness study, at the Medical College of Wisconsin. You are invited to participate in this research study, which involves your submission of identifiable personal information. It will take 15 minutes to complete the enrollment form. Your participation in this study is voluntary. The information is used for several purposes: to identify candidates for this study and to ensure that the reported data is accurate and matches the fMRI scans.

Your consent to participate is identified in two ways:

1. Submission of a completed enrollment form. It may take up to 15 minutes to fill out the enrollment form. Your personal information, which includes health information, is requested in the enrollment form. Your personal information will be held until 2026.

2. Participation in fMRI scanning sessions. Based upon the information provided in the enrollment form and entered in the database/registry, you will be considered for this study. You may be contacted by the study coordinator. Each fMRI scanning session is research and you must give your consent to participate before engaging in any research related activities. In other words, you will sign other consent forms before actually participating in the study.

The risk associated with providing your personal information for use in this study is the potential for breach of confidentiality (someone learning of private information about you without your permission). Your personal information is forwarded by email to the study coordinator’s computer, which is password protected. The data is protected by allowing only the study coordinator, Dr. Lauer or her anesthesiologist designee, and Dr. Hudetz direct access to the information. In the event of a security breach, the cause of the breach will be investigated.

There is no known benefit for you to participate in this study; however there may be some benefit to society resulting from future research studies.

If you do not want your personal information to be held until 2026, please do not submit your information.

Your participation in the research study is voluntary and you may discontinue your participation at any time. If you decide to withdraw from the study, your decision will have no impact on the quality of current or future medical care you receive, academic standing or job status.

If you have any further questions or require additional information, feel free to contact our study coordinator at 414-955-4956. If you have any questions regarding your rights or responsibilities as a research participant, please contact the Medical College of Wisconsin Human Research Protection Office Quality Assurance and Compliance Coordinator at 414-955-8844.

If you are interested in participating, please fill in your name and click submit. Then, you can proceed to the enrollment form. This process requires you to submit personal information, including health information, which will be kept strictly confidential and available only to research personnel with security clearance. If you would prefer to enroll over the phone, call 414-955-4956.




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Page Updated 02/10/2014