Consent

Attachment H –Patient Consent Form

Why is this study being done?

The purpose of this study is to help UCSF improve how physicians, nurses, and pharmacists can help better treat pain and improve rehabilitation of patients while they are in the hospital.

As part of this project, we are surveying patients to learn more about how well they can walk and care for themselves, and how they manage their pain both in the hospital and afterwards.

How many people will take part in this study?

About 2000 people will take part in this study.

What will happen if I take part in this research study?

If you agree to take part in this study, you will first complete questionnaires about your physical function, pain, and things you do to manage pain. This takes about 10 minutes and will take place in your room at UCSF.

In order to see how you recover after you leave the hospital, we will then repeat this survey at 14 days, 30 days, and 60 days after you leave the hospital. This survey can be completed electronically or by phone. Each survey will take about 10 minutes to complete,

How long will I be in the study?

This study will last until 2020. Your participation in the study will end after you complete the final survey at 60 days.

Can I stop being in the study?

Yes. You can decide to stop at any time. Just tell the study researcher or staff person right away

if you wish to stop being in the study.

What side effects or risks can I expect from being in the study?

Participation in this research may involve some loss of privacy. However, your records will be

handled as confidentially as possible. Access will be limited to the study researchers and will

require a password. Your contact information will not be shared with anyone outside the lab.

Are there benefits to taking part in the study?

There will be no direct benefit to you from participating in this study. However, the information

that you provide may help health professionals better understand how to improve patient care.

What other choices do I have if I do not take part in this study?

You are free to choose not to participate in the study. If you decide not to take part in this study,

there will be no penalty to you. You will not lose any of your regular benefits, and you can still

get your care from our institution the way you usually do.

Will information about me be kept private?

We will do our best to make sure that the personal information gathered for this study is kept

private. However, we cannot guarantee total privacy. Your personal information may be given

out if required by law. If information from this study is published or presented at scientific

meetings, your name and other personal information will not be used.

Organizations that may look at and/or copy your research records for research, quality assurance,

and data analysis include: The University of California

What are the costs of taking part in this study?

You will not be charged for any of the study treatments or procedures.

Will I be paid for taking part in this study?

You will not be paid for taking part in this study.

What are my rights if I take part in this study?

Taking part in this study is your choice. You may choose either to take part or not to take part in

the study. If you decide to take part in this study, you may leave the study at any time. No matter

what decision you make, there will be no penalty to you in any way. You will not lose any of

your regular benefits, and you can still get your care from our institution the way you usually do.

Who can answer my questions about the study?

You can talk to the researchers about any questions, concerns, or complaints you have about this

study. Contact the study Principal Investigator, Andrew Auerbach MD 415-502-1414

If you wish to ask questions about the study or your rights as a research participant to someone

other than the researchers or if you wish to voice any problems or concerns you may have about

the study, please call the Office of the Committee on Human Research at 415-476-1814.