PI: Bryan IRB # 14-041, V1 – 10/21/15 expires
Consent Form: “Trauma, Health & Hazards Center Participant Registry”
The Trauma, Health, & Hazards Center at the University of Colorado Colorado Springs (UCCS) 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 participating in research studies at
UCCS. If you decide to participate, we’ll record your name, gender, year of birth, race, ethnicity, veteran/military
status, phone number, email, and mailing address. Even if you decide not to provide all of this information, you
can still be added to the database.
University faculty members affiliated with the UCCS Trauma, Health, & Hazards Center have access to this
Database. UCCS 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.
In some cases you may be financially compensated for your participation. You are free to decline any invitation to
participate in a study. You may request to have your information removed from the Database at any time.
Your identity will be kept confidential. All participant information in the Database is kept in 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 UCCS Trauma, Health & Hazards Center.
If you have questions regarding this database, you may contact the principal investigator, Lori Bryan (719-2555185). Contact the Research Compliance Coordinator at 719-255-3903 or via email at irb@uccs.edu:
• if you have questions about your rights as a research participant, or
• if you have questions, concerns or complaints about the research.
Your signature acknowledges that you have read and understand the information stated.
Signature:
Date:
Please complete any or all of the following items:
Name:
Gender:
Your Year of Birth:
Phone #:
Address:
Email:
male
female
Preferred method of contact: Email
Please circle your ethnicity: 1. Hispanic
Please circle your race:
1. White
2. Black or African American
3. Native Hawaiian or Other Pacific Islander
4. American Indian or Alaska Native
5. Asian
6. More than one race
7. Other or unknown
Phone
2. Non-hispanic
Please indicate your veteran or military status:
1. Veteran
2. Active Military/Reserve
3. Civilian
4. Other (indicate):
Please return to: Lori Bryan, UCCS Trauma Health & Hazards Center, 4863 North Nevada Avenue,
Room 368, Colorado Springs CO 80907 or lbryan@uccs.edu