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Columbia University Medical Center
Consent Form to Participate
Alopecia Areata Screening and Recruitment Registry
1. Title of research study and general information
Alopecia Areata Screening and Recruitment Registry
2. Researchers’ contact information
Julian Mackay-Wiggan, MD, MS
3. What information is on this form?
This form explains why we are doing this registry and what you will be asked to do if you choose to take part in the registry. It also describes the way we (Researchers) would like to use information about you. Please take the time to read this form.
You do not have to participate if you don’t want to.
4. Why is this study being done?
The Alopecia Areata Screening and Recruitment Registry is set up for the registration and data collection of all individuals who are interested in participating in our alopecia areata studies.
5. What will I be asked to do if I choose to be in this study?
If you are interested in possible participation in any of our alopecia areata studies, you will be asked to provide your name, contact information and basic information regarding your hair loss. The online form must be filled out completely to be considered for an alopecia study and we will respond in the order that your online form is received. Unfortunately, we are not able to respond to direct email or phone call queries regarding participation in the studies.
The Alopecia Areata studies at Columbia University Medical Center are small studies with limited enrollment. We will therefore not be able to screen or enroll everyone who is interested. However, we will review all information provided via the online form and respond based on the order of receipt. If you are eligible for a particular project, consent procedures will be obtained under that separate approved protocol. In addition, we will save your information and may contact you regarding future studies if you indicate that you wish us to do so. Only the Columbia study staff will have access to the information you provide in the online form.
6. Will I qualify for any of your current alopecia areata studies?
Have alopecia areata, alopecia totalis, or alopecia universalis
Are at least 18 years old.
Are in good general health
Are able to travel, at your own expense, to Columbia University Medical Center in New York City (or University of Minnesota for Intralesional Triamcinolone) on at least a monthly basis for study visits. Insome cases, visits may be more frequent, and it is important that you be able to come in for unscheduled visits if necessary. Therefore, ideal candidates should live within driving distance of CUMC.
We are not able to cover travel costs, and it is not possible to be seen at other sites outside of NYC, with the exception of University of Minnesota for Intralesional Triamcinolone.
Note the above requirements may change for future studies.
7. Are there any risks?
Loss of confidentiality.
A risk of taking part in this study is the possibility of a loss of confidentiality or privacy. Loss of privacy means having your personal information shared with someone who is not on the study team and was not supposed to see or know about your information. The study team plans to protect your privacy. Their plans for keeping your information private are described in section 9 of this consent form.
8. Are there any benefits?
You will not benefit from taking part in this registry, but your participation may help people who have Alopecia Areata in the future.
9. What about my privacy?
Every effort will be made to keep your personal information confidential. However, we cannot guarantee total privacy.
The following people and/or agencies will be able to look at and copy your research records:
The investigator, study staff and other professionals who may be evaluating the study;
Authorities from Columbia University and New York-Presbyterian Hospital, including the Institutional Review Board ('IRB'). An IRB is a committee organized to protect the rights and welfare of people involved in research.
The Office of Human Research Protections ('OHRP')
10. Will I get paid or be given anything to take part in this study?
You will not receive any payment or other reward for taking part in this study.
11. Will I incur costs if I take part in this study?
There will be no costs to you for being in this study.
12. What are my rights if I take part in this study?
Taking part in this registry is your choice. You can decide not to take part in the registry. Your choice will not change the treatment you receive from doctors and staff at Columbia University Medical Center and New York-Presbyterian Hospital.
Please note that you may change your mind and revoke “take back” this authorization at any time for any reason. To revoke this authorization you must contact the Principal Investigator Julian Mackay-Wiggan, MD, MS at telephone number 212-305-6953. However, even if you revoke this authorization, the researchers may continue to use and disclose the information already collected, however new information will not be collected for this research purpose. Use of this information / your HIPAA authorization will expire at the end of this research.
If you have any questions about your rights as a subject, you may contact the Institutional Review Board at
(212) 305-5883 or by email at email@example.com. An Institutional Review Board is a committee organized
to protect the rights and welfare of human subjects involved in research.
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