El Centro Regional Medical Center
CONSENT TO ACT AS A RESEARCH SUBJECT
COVID-19 Prevention Network (CoVPN) Volunteer Screening Registry
El Centro Regional Medical Center is conducting research about COVID-19. We are collecting information about members of the community who are interested in participating in COVID-19 research.
You may be eligible to participate in one or more of these research studies. If you agree, you will complete a questionnaire about yourself, your health and your living situation to see if you are eligible.
Benefits of participation may vary but may include test results, treatments and/or compensation. All personal information is strictly confidential. Study participation is voluntary and done for research purposes only.
There is a risk of loss of confidentiality when you provide your name and contact information. We will do everything we can to protect your privacy and will never share your information. There is no direct benefit for providing your contact information and agreeing to be contacted about research studies, but
you may learn of a study that interests you. You will not be compensated for providing your information.
The alternative to completing this form is choosing to not participate. If you decide later that you no longer want to be contacted about research studies at El Centro Regional Medical Center you can tell us when we contact you. We'll remove your information from our contact list. You could also contact us via telephone at (760) 339-4085.
If you are interested in completing the questionnaire and hearing more about research so that you can choose whether or not to become involved, please type your name below indicating you agree to participate.
By typing your name below, you are agreeing to complete a screening questionnaire and are not committing to become involved in any study.
I am interested in learning more about research studies being conducted by El Centro Regional Medical Center.