Community Consultation / Public Notification Opt Out Form
In response to the information I have received regarding the upcoming ProTECT III 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, “ProTECT Declined”, for the Emergency Department Staff 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 Health Care Staff 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 has had a Traumatic Brain Injury 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
Name:__________________________________ Wrist Size (Sm, Lg, Xlg):_____________
City, State, Zip:______________________________________________________________
Date:__________ Signature: ________________________________________________