Electronic consent form
Version Date: 15 November 2017
If you think you experienced a strange exposure during a trip you took to Havana, Cuba, we are asking you to take part in a research study. This form gives you information about the study. It describes the purpose of the study, and the risks and possible benefits of participating in the study.
This study is voluntary and it involves filling out a short survey online that you will be directed to if you agree to and complete this consent form. You do not have to take part in this study if you do not want to. If you do start to complete the survey and you change your mind, you can leave at any time by exiting the survey without hitting SUBMIT.
Why are you being asked to take part in this study?
You are being asked to take part in this study because you believe you experienced a strange exposure during a trip you took to Havana, Cuba.
What is the purpose of this study?
The purpose of this study is to learn more about what people experienced and how the exposure affected them. We also would like to know how many people were exposed.
How many people will take part?
We do not have a good idea about how many people will take part.
What is involved in the study?
The study involves completing a short online survey. The survey asks about what you experienced, such as noises or any sensation, and how you may have been affected such as having symptoms like a headache.
How long will you be in this study?
If you agree to take part, completing the survey will take about 10 minutes.
What are the study procedures?
The study involves completing a short online survey.
What are the risks of this study?
This study does not involve any foreseeable risks.
Are there any benefits to taking part in this study?
There will be no direct benefit to you from taking part in this study.
Do you need to give your consent in order to participate?
If you decide to participate in this study, you must check the box at the end of this form.
What happens if you decide not to take part in this study?
Participation in this study is voluntary. You do not have to take part if you don’t want to.
What about privacy and confidentiality?
The survey will not ask any information that will allow you to be personally identified. For example we do not ask for your date of birth or address.
Will you be paid for taking part in this study?
You will not be paid for taking part in this study.
Who is funding this research study?
This study is not funded.
What if you have questions about the study?
The Institutional Review Board (IRB) at the University of Pennsylvania has reviewed and approved this study. The IRB looks at research studies like these and makes sure research subjects’ rights and welfare are protected. If you have questions about your rights or if you have a complaint, you can call the IRB Office at 215-573-2540.