Consent for Online Enrollment

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, The Epilepsy Connectome Project (ECP), at the Medical College of Wisconsin and University of Wisconsin - Madison. The purpose of the ECP study is to understand how brain networks differ in people with temporal lobe epilepsy and to test theories and methods for predicting the clinical course and response to medical and surgical treatments in people with this condition.

You are invited to participate in this research study, one portion of which involves your submission of identifiable personal information.  If you sign this form, you give the study team permission to review this identified personal information.  The information is used to identify candidates for this study and to coordinate with you the completion of any authorization forms needed to release epilepsy-related medical information to approved members of the study team.

If the information from the enrollment form makes you eligible to participate, a study team member will contact you to discuss the next steps before your initial study visit. You will then make an appointment with a study team member to come in for your initial study visit, at which point you will be presented with a separate consent form along with additional information about the study.

If you have more questions or would like specific details about the study, please contact Megan Rozman at (414) 955-4485.

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 10 years after the study ends. Based on the information provided in the enrollment form you are allowing the study team to review your personal information and see if you meet the qualifications for this study. If you meet the criteria for the study, you will be contacted by the study coordinator. At the first study visit, you will sign a separate written consent form before participating in any study activities.

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 coordinators and Principal Investigators direct access to the information. In the event of a security breach, the cause of the breach will be investigated.

This study will not help you directly, but we hope the information from this study will help us develop better methods of predicting the clinical course and response to medical and surgical treatments for epilepsy.

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 one of the study coordinators listed below. 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 information below 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, please contact one of the study coordinators listed below.

Medical College of Wisconsin, Milwaukee
Megan Rozman, MPH
mrozman@mcw.edu
(414) 955-4485

University of Wisconsin, Madison
Dace Almane
almane@neurology.wisc.edu
(608) 265-4242


 

Name: 

Email: 

Phone: 

Preferred Study Location (Milwaukee or Madison): 

 

 


Understanding brain networks in people with epilepsy

Jeffrey Binder, MD, Study Leader | Department of Neurology, Froedtert Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226
 

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