1 survey

O.M.B. 0928-0281
Exp. XX/XXXX

ARIC

INFORMED CONSENT TRACKING FORM

Atherosclerosis Risk in Communities
ID NUMBER

CONTACT YEAR

LAST NAME

FORM CODE

I

C

T

VERSION: B 05/22/07

INITIALS

Public reporting burden for this collection of information is estimated to average 0 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0281). Do not
return the completed form to this address.

INSTRUCTIONS: ID Number, Contact Year and Name must be entered above. Whenever numerical responses
are required, enter the number so that the last digit appears in the rightmost box. Enter leading
zeroes where necessary to fill all boxes. On the paper form, if a number is entered incorrectly,
mark through the incorrect entry with an "X". Code the correct entry clearly above the incorrect
entry. For "multiple choice" questions, circle the letter corresponding to the most appropriate
response. If a letter is circled incorrectly, mark through it with an "X" and circle the correct
response

INFORMED CONSENT TRACKING FORM (ICTB screen 1 of 2)
2.a. Change in restrictions on
use/storage of study data? ………….. Yes

A. POST-VISIT CONSENT MODIFICATION
1.a. Change in restrictions on
use/storage of DNA? ………….. Yes

Y
Go to Item 3.a.

Go to Item 2.a.

b.

No

Type of restriction
On use/storage of DNA?

N

b.

No

Type of restriction
On use/storage of study data?
Full use ………………… F

Full use ………………… F

CVD research …………... C

CVD research …………... C

ARIC only ………………. A

ARIC only ………………. A

Other ……………………. O

No use/storage
Of DNA ……………….. N

Specify details of DNA restrictions:
____________________________________________

Other ……………………. O
____________________________________________
Specify details of DNA restrictions:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________

Y

N

INFORMED CONSENT TRACKING FORM (ICTB screen 2 of 2)
3.a. Change in permission to
access medical records? ……. Yes
No

Go to Item 4.

b.

B. ADMINISTRATIVE INFORMATION
Y
N

Type of restriction on access
to medical records:
Full access

…………….. F

No access

…………...... N

Partial access …………… P
If partial, specify: ___________________
______________________________________
______________________________________
______________________________________

4.

Date of data Collection:

M M

/

D D

/

5. Code number of person
completing this form:

Y Y Y

Y