School of Rural Health
Sydney Medical School
ABN 15 211 513 464 ARCHER 2 INVESTIGATORS Prof Kate Steinbeck Dr Krestina Amon Prof Andrew Campbell Dr Hoi Lun (Helen) Cheng Dr Chin Moi Chow Prof David Handelsman Dr Georgina Luscombe A/Prof Catherine Hawke Prof Philip Hazell Prof Rebecca Ivers Dr Patrick Kelly Mrs Karen Paxton Dr Margot Rawsthorne A/Prof Rachel Skinner Research Office Suite 7, 77 Myall Street PO Box 1043
DUBBO NSW 2830 Telephone: 02 6882 0288 Facsimile: 02 6884 1829
Email: [email protected]
Web: www.archerstudy.org.au
Cognitive Assessment Participant Supplementary Consent Form
1. About the test. This is an automated test of your thinking. This is a series of tests designed to assess your cognitive strengths and weaknesses. The tests are conducted on windows computer. You will not need any computer skills to complete these tests. 2. What happens to your responses? Your responses will be sent to the Brain Resource Company for centralized analysis via a secure internet connection. Your responses will be compared to others of the same age, sex and years of education in the Brain Resource International Database. Brain Resource will provide a report to the ARCHER 2 investigators. 3. The privacy and confidentiality of your information is assured. All details that personally identify you will be removed from the data and replaced by your an anonymous ID key before transmission. The central processing facility will not receive your name, only your anonymous ID key. Your name will be held in strict confidence here at your local clinic and stored separately and independently of the database. 4. Request permission to include your data in the International database. With your permission, your de‐linked data will be included in the Brain Resource International Database, and may be made available for scientific, clinical and commercial purposes. I understand that I do not have to consent to my data being included in the Brain Resource Database and still participate in the current study without prejudice. I understand that, if I initially choose to consent, I can subsequently withdraw my consent to the future usage of my data at any time. I understand and agree that scientists internationally may have access to data from this test at any time in the future and that the information may be used for scientific, clinical or commercial purposes. I understand and agree that no personal identification information (i.e. name, address, contact details) will be transmitted to the central international database. Yes
No
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Parent’s/carer’s signature: Adolescent’s signature: PRINT name: PRINT name: Date: Date: PCF Cognitive Assessment Participant Supplementary Consent Form
Version 1 Approved July 2015