Department of Emergency Medicine

Community Consultation / Public Notification
Opt Out Form

In response to the information I have received regarding the upcoming RAMPART study, I choose to not participate or to opt out of the study. I am aware that I must mail this form to the address listed below and I will then be mailed a bracelet upon receipt of this form. The bracelet will have an alert, “RAMPART Declined”, for the Emergency Medical Service departments to let them know that I will not be participating.

I am aware that I must wear this bracelet at all times on my wrist in order to be assured that I will not be enrolled into the study. I understand that Paramedics have been trained to look on my wrist for this bracelet and if I am wearing it, they will know that I am not to be enrolled as a study participant. I will still receive the standard care that is given to someone who is having a seizure and will not be penalized for not participating.

This study is expected to last up to five years.

If I have any questions regarding the study, I can use the following contact information:

Emergency Research Coordinator
Medical College of Wisconsin
Department of Emergency Medicine
Froedtert East Hospital / Pavilion Bldg 1P
9200 West Wisconsin Ave.
Milwaukee, WI 53226
414-805-0345
emsresearch@mcw.edu
www.mcw.edu/rampart

Name:__________________________________ Wrist Size (Sm, Lg, Xlg):_____________

Address:____________________________________________________________________

City, State, Zip:______________________________________________________________

Date:__________ Signature: ________________________________________________