Final project

THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S INFORMED CONSENT LETTER AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101 .

For Official Use Only
Date received:
Date reviewed:
End date:
File #:

SELF CONSENT

I have been invited to take part in a research study titled:

This study is being conducted by Kenya Leyva , who can be contacted at:786-391-5874

I understand that my participation is voluntary and that I can refuse to participate or stop taking part any time without giving any reason and without facing any penalty. Additionally, I have the right to request the return, removal, or destruction of any information relating to me or my participation.

PURPOSE OF STUDY

I understand that the purpose of the study is to:

Implement a multidisciplinary approach as a strategy to prevent readmissions for 65 years and older patients diagnosed with Heart Failure discharged home.

PROCEDURES

I understand that if I volunteer to take part in this study, I will be asked to:

Participate in an experimental group where the multidisciplinary approach will be implemented. Follow up visits with NP to assess understanding of disease condition, treatment plan, education related medications and hospital admissions. Social worker and case management for community resources, insurance options.

BENEFITS

I understand that the benefits I may gain from participation include:

• An opportunity to improve quality of life for heart failure patients.

• An opportunity to help reduce readmissions rate in the elderly population diagnosed with heart failure.

• Contribute to educated heart failure management from home using a plan of care that best meet the patient’s needs and include all possible resources.

RISKS

I understand that the risks, discomforts, or stresses I may face during participation include:

Time management while conducting the study.

CONFIDENTIALITY

I understand that the only people who will know that I am a research subject are members of the research team. No individually-identifiable information about me, or provided by me during the study will be shared with others except when necessary to protect the rights and welfare of myself and others (for example, if I am injured and need emergency care, if the provided information concerns suicide, homicide, or child abuse, or if revealing the information is required by law).

FURTHER QUESTIONS

I understand that any further questions that I have, now or during the course of the study can be directed to the researcher ( Kenya Leyva 786-391-5874 ).

Additionally, I understand that questions or problems regarding my rights as a research participant can be addressed to Dr. Jessica Hillyer, Institutional Review Board Director of Compliance and Training, South University, 7700 W. Parmer Ln., Austin, TX 78729;

[email protected] ; 512-516-8779.

My signature below indicates that the researchers have satisfactorily answered all of my current questions about this study and that I understand the purpose, procedures, benefits, and risks described above. I have also been offered a copy of this form to keep for my own records.

Kenya Leyva

Participant Printed Name

Kenya Leyva

Signature of Participant Date 10-12-2020

Kenya Leyva

Signature of Principal Investigator Date 10-12-2020

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