GCRC

University of Illinois at Chicago
Clinical Research Center

Clinical Research Healthy Control Subject Registry

Thank you for your interest in volunteering as a research study healthy control subject at the University of Illinois at Chicago Clinical Research Center (CRC). This form is to be used if you would like to be added to the general database of healthy control subjects for possible participation in any research study, now or in the future, in the CRC. Filling out this form in no way obligates you to participate in a study, but may result in one or more contacts by phone or e-mail assessing your interest and suitability for research trials. You may modify or withdraw your information at any time by following the directions listed at the bottom of this web page.

The information you provide will be made available to researchers who will contact you directly should your profile meet the needs for a particular study. Participation in clinical research studies is voluntary, and may require visits to the University of Illinois at Chicago Medical Center.

The following questions must be answered to participate in the registry.

Note: (*) is required field

* First Name:
*Last Name:
*Street Address:
*City:
*State:
*Zip Code:
Email address (if you have one):
*Phone: Day:		Evening:
*Gender:
*Date of Birth:	Mo: Day:	Yr:
*Height:	Feet: Inches:
*Weight (pounds):
*Do you consider yourself healthy?
*How do you prefer to be contacted:


The remaining questions are not required, but may be helpful in screening your information for potential study matches.
Race:
Do you smoke?
Do you drink alcohol?
Are you presently taking any prescription medications?
(List prescription medications if you answered Yes to the above question)
Are you presently taking any over-the-counter medications?
(List over-the-counter medications if you answered Yes to the above question)
Have you participated in any previous research studies?
(List previous research studies if you answered Yes to the above question)


Are you submitting now to request an update to previously entered information?
Are you submitting now to request to removal of information from this registry?


Please read the following information before using the submit button to transmit your information.

Potential Risks: There are no risks of physical harm associated with participation in the registry. Participation does involve the potential risk of loss of confidentiality. This risk will be minimized by removing your name from the information stored in the registry; securing, in a separate location, and limiting access to information linking the code assigned to your registry information with your name; and limiting access to CRC investigators. Investigators requesting use of the registry will sign a letter agreeing to use appropriate safeguards to prevent use of registry information except to identify potential healthy control subjects. There is also a potential risk that those in the registry who consent to participate in more than one study may be vulnerable to the effects of multiple blood draws and/or radiation exposure. It is very important that prior to participating in a research study, you inform the investigator if you are presently or in the recent past have participated in another study.

Benefits: There are no benefits to participating in the registry.

What if I am a UIC student? You may choose not to participate or to stop your participation in this registry at any time. This will not affect your class standing or grades at UIC. You will not be offered or receive any special consideration if you participate in this registry.

What if I am a UIC employee? Your participation in this registry is in no way a part of your university duties, and your refusal to participate will not in any way affect your employment with the university, or the benefits, privileges, or opportunities associated with your employment at UIC. You will not be offered or receive any special consideration if you participate in this registry.

The information you submit may be retained and used indefinitely. You may remove or request an update of the information that you have provided to the registry at any time by submitting your request via this web site. You may also contact the registry's study coordinator in writing to update or remove your information from the registry.
Study Coordinator Name: Vamsi Vasireddy
Mailing Address: Clinical Research Center (M/C 521) University of Illinois Medical Center at Chicago 1740 West Taylor Street Chicago, Illinois 60612-7243

By clicking the "SUBMIT" button at the bottom of this web page, you are consenting to become a participant in the University of Illinois at Chicago Clinical Research Center Healthy Control Subject Registry.