[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-307147-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-307147-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","participant-informed-consent-form-and-authorization-to-use-and-disclose-medical-information-version-19-january-2022","Participant Informed Consent Form and Authorization to Use and Disclose Medical Information - Version 19 January 2022","","Participant informed consent form for the University of Georgia Mind Your Heart Pilot Study. It explains the study purpose of evaluating whether nutrition education improves eating habits and health measures including blood lipids and blood pressure, and describes procedures such as initial and final visits, blood draws, eye exam nutrient measurements, blood pressure, and anthropometrics. It also details use of the eLC platform for reviewing six online modules over six weeks and weekly texted questionnaires. Participation is voluntary with no direct benefits, and access to educational and pre/post screening results is provided.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/participant-informed-consent-form-and-authorization-to-use-and-disclose-medical-information-version-19-january-2022/307147/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/participant-informed-consent-form-and-authorization-to-use-and-disclose-medical-information-version-19-january-2022/307147.png","ImageObject",442,249,{"name":42,"@type":43},"Anna Hans","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-07","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",5,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is the purpose of the Mind Your Heart Pilot Study?","Question",{"text":63,"@type":64},"The study examines whether nutrition education improves eating habits and health measures such as blood lipids and blood pressure.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What will participants be asked to do during the study?",{"text":68,"@type":64},"Participants will attend an initial visit for consent, training, questionnaires, an eye exam, and blood and vital measurements, then complete six online modules on the eLC platform and weekly questionnaires, and finally attend a final in-person visit for repeat assessments.",{"name":70,"@type":61,"acceptedAnswer":71},"Is participation voluntary, and can someone stop at any time?",{"text":72,"@type":64},"Yes. Participation is voluntary, and participants may choose not to take part or stop at any time without penalty or loss of benefits.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},307147,1790632868,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,114,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},17,"Forms",40,"forms",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":116,"slug":117},18,30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},21,"Paper Templates","papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":115,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":30},5909892332657,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","PROTOCOL NO: PROJECT00003799  \nSTERLING IRB ID: \u003CIRB ID>  \nPARTICIPANT INFORMED CONSENT FORM AND AUTHORIZATION TO USE AND DISCLOSE MEDICAL INFORMATION  \nSTUDY TITLE: University of Georgia Mind Your Heart Pilot Study  \nPROTOCOL NO: PROJECT00003799  \nSTUDY  \nINVESTIGATOR: \u003CFirst Name> \u003CMiddle Name> \u003CLast Name> , \u003CSuffix>  \nSTUDY SITE: \u003CCompany Name>  \n\u003CAddress>  \n\u003CCity, State, ZIP>  \nTELEPHONE: \u003CTelephone>  \n\u003CTelephone \\#2, if applicable>  \nSPONSOR: University of Georgia  \nYou are being asked to take part in a research study. The information in this form will help you decide if you want to be in the study. Please ask the researcher(s) below if there is anything that is not clear or if you need more information.  \nStudy Investigators:  \nLisa Renzi-Hammond, PhD and Anita Reina, MS  \nHealth Promotion and Behavior  \n[lrenzi@uga.edu](lrenzi@uga.edu) , [anita.reina@uga.edu](anita.reina@uga.edu) , [MindYourHeart@uga.edu](MindYourHeart@uga.edu)[ ](MindYourHeart@uga.edu)[The following is key information to consider about your participation.](The following is key information to consider about your participation.)  \n▪ The purpose of this study is to examine if nutrition education improves eating habits and health measures, such as blood lipids and blood pressure.  \n▪ Your involvement in the study is voluntary, and you may choose not to participate or to stop at any time without penalty or loss of benefits to which you are otherwise entitled.  \n▪ If you choose to participate, you will first be asked to visit the Institute of Gerontology on the Health Science Campus. We will ask you to provide information about your eating habits, and you will have blood drawn by a trained phlebotomist to measure your blood lipids, like cholesterol. We will measure your blood pressure and measure nutrients in your eyes during an eye exam. Before and after the 6-week period, you will be asked to complete an online questionnaire and provide follow-up blood samples, blood pressure measurement , and an eye exam. This visit should take about an hour to complete.  \n▪ You will be given access to the Mind Your Heart program on e-Learning Commons (eLC) . You will be asked to review 6 modules online over the next 6 weeks. Each module should take between 20-30 minutes to complete. The full program may take 4 to 6 hours over 6 weeks.  \nPage 1 of 7  \nVersion Date: 19 January 2022  \nDATE APPROVED BY STERLING IRB: 24 JAN 2022  \nPROTOCOL NO: PROJECT00003799  \nSTERLING IRB ID: \u003CIRB ID>  \n▪ After the 6-weeks is over, we will ask you to return to the Institute of Gerontology to repeat the tests you completed on your first visit.  \n▪ There are no direct benefits in participation, although this program will allow you to access evidence-based nutrition education and eating behaviors at any time on a web-based platform. You will also have access to your pre- and post-study health screening including blood pressure, cholesterol levels, and eye nutrient levels.  \n▪ As an alternative to this research study, the University of Georgia offers nutrition education and mindfulness programs through UGA Well-Being. Contact your human resources department to learn more about how to participate  \n▪ You have been asked to participate because you are a UGA employee and have confirmed that you meet the inclusion criteria for the study. If you are interested in participating in the study, please read the additional information on the following pages, and feel free to ask questions at any point.  \nStudy Procedures and Time Commitment  \nThe purpose of this study is to learn whether virtual nutrition education can effectively help you learn and maintain healthy eating habits.  \nApproximately 50 people age 18 and older will participate in this study. If you choose to participate, you will be asked to:  \n1. Attend an initial study visit. During this visit, you will:  \no Complete the informed consent process.  \no Receive training on how to access Bright Space Desire2Learn electronic learning management ","cbCaii2CrJRuIXxN","https://ap.wps.com/l/cbCaii2CrJRuIXxN","pdf",188413,7,"English","# Key study information\n## Purpose and voluntary participation\n## Study procedures and time commitment\n## Data collection and measurements\n## eLC educational modules and questionnaires\n## Risks, benefits, and alternatives","[{\"question\":\"What is the purpose of the Mind Your Heart Pilot Study?\",\"answer\":\"The study examines whether nutrition education improves eating habits and health measures such as blood lipids and blood pressure.\"},{\"question\":\"What will participants be asked to do during the study?\",\"answer\":\"Participants will attend an initial visit for consent, training, questionnaires, an eye exam, and blood and vital measurements, then complete six online modules on the eLC platform and weekly questionnaires, and finally attend a final in-person visit for repeat assessments.\"},{\"question\":\"Is participation voluntary, and can someone stop at any time?\",\"answer\":\"Yes. Participation is voluntary, and participants may choose not to take part or stop at any time without penalty or loss of benefits.\"}]","Participant Informed Consent Form and Authorization to Use and Disclose Medical Information - Version 19 January 2022 | PDF",1789844843]