Subject Contact Information Form

After submitting the screening questionnaire, you will be contacted by a research coordinator who will conduct a phone interview and complete enrollment. Please read the following document for more information about the Registry.

toll free phone: 888-365-9901

e-mail: wpdr@u.washington.edu

mailing address: 1660 S. Columbian Way MS-127
Seattle, WA 98108

Text of Information Statement:
September 11, 2012 PRINCIPAL INVESTIGATOR: Cyrus Zabetian, MD, MS RESEARCHERS: Cyrus Zabetian, MD, MS, Associate Professor, Dept. of Neurology James Leverenz, MD, Professor, Dept. of Neurology Ali Samii, MD, Professor, Dept. of Neurology Debby Tsuang, MD, MSc, Professor, Dept. of Psychiatry & Behav. Sci. Mike Kim, MD, Acting Assistant Professor, Dept. of Neurology Shu-Ching Hu MD, PhD, Assistant Professor, Dept. of Neurology Veronica Hicks, PA-C, Dept. of Psychiatry & Behav. Sci. Gretchen Todd, PA-C, Dept. of Psychiatry & Behav. Sci. Sindhu Srivatsal, MD, Movement Disorders Fellow, Dept. of Neurology Marie Davis, MD Movement Disorder Fellow, Dept. of Neurology Erica Martinez, Research Supervisor, SIBCR Marne Baca, Research Coordinator, SIBCR Sydney McPhearson, Research Coordinator, SIBCR Jennifer Pate, Research Coordinator, SIBCR Sarah Heniges, Research Assistant, SIBCR Gigi Streidl, Research Associate, Dept. of Neurology Sara Kath, Research Associate, SIBCR Heli Venkov, Research Assistant, SIBCR Kristin Murphy, Research Assistant, Dept. of Neurology Emily Ashmore, Research Assistant, SIBCR Tiffany Thompson, Research Assistant, SIBCR Sam Jewell, Research Assistant, SIBCR Renee Agatsuma, Research Assistant, Dept of Neurology Selena Corbett, Research Associate, SIBCR Darla Chapman, RN, Dept. of Psychiatry & Behavioral Sciences If you have any questions about this form, please feel free to contact us at 206-277-6080 or 888-365-9901. RESEARCHERS' STATEMENT You are being invited to participate in a research study. The purpose of this Information Statement is to give you the information you will need to help you decide whether to be in the study. Please read this form carefully. You may ask questions about the purpose of the research, what we would ask you to do, the possible risks and benefits, your rights as a volunteer, and anything else about the research or this form that is not clear. When we have answered all your questions, you can decide whether you want to be in the study. This process is called "informed consent." You may keep this form for your records. PURPOSE OF THE STUDY The purpose of this research study is to create and maintain a database registry of information from people with Parkinson disease or related disorders in Washington State who are interested in participating in research studies. People with a diagnosis of atypical parkinsonism, including progressive supranuclear palsy (PSP), multiple system atrophy (MSA), corticobasal degeneration (CBD), and dementia with Lewy bodies (DLB), are also eligible to participate in the Registry. The database will consist of information about the subject�s disease and contact information in order to make it easier for researchers to enroll people into new research studies. Different investigators from the University of Washington and non-University of Washington affiliated institutions will conduct these research studies. By creating this registry, we hope to improve access to those who are willing to participate in research studies and to facilitate the recruitment process for researchers. We are asking you to give us verbal consent in order to obtain details of your disease, your biographical information, and your permission to be contacted for future research studies. Your participation is completely voluntary and there is no cost to participate in these research studies. If you consent to these terms, we will include you in the Washington Parkinson Disease Registry and contact you in the future when suitable research studies arise. PROCEDURES We will follow these procedures: Screening Process: If you express an interest in participating, you will be asked 15 questions to determine your eligibility for the Registry. These include questions about diagnosis, medications, and symptoms. If you meet the basic criteria for inclusion in the study, we will explain the purpose, procedures, benefits, and risks of participation outlined in this Information Statement. Consent Process: While most consent forms require your signature and a witness signature, we will be asking for verbal consent either over the phone or in person. This process is described as a waiver of written consent. Other than the difference in asking for verbal consent, there is absolutely no difference in the degree of security or confidentiality in this process. You might not be able to provide verbal consent for several reasons, including: 1. You might have diminished decision-making capacity 2. Your disease might have affected your ability to communicate (e.g., soft voice, slurred speech) Under these circumstances, we will ask your legally authorized representative (guardian, durable power of attorney, spouse or other next of kin) to provide verbal consent. In addition, we will need to establish your willingness to participate in the Registry by asking your permission to be included in the Registry. Data Acquisition: Once we verify that you have provided verbal consent, a Registry Coordinator will collect the following information: • Biographical information such as name, address, phone number, date of birth, ethnicity, and email address. • Medical information such as initial and current symptoms related to Parkinson disease, medications, complications from medications, history of deep brain stimulation (if applicable) and family history of Parkinson disease. • Your interest in participating in various types of studies such as drug trials, genetics research, studies on environmental exposures, and "biomarker" research. We will also ask for your legally authorized representative's contact information (phone number, address, email) if different from yours. This is necessary since it will facilitate the follow-up/ update process. The interview process will occur over the phone or in person and should take no more than one hour. The interview can be made shorter and easier if you can prepare a list of medications and doses, physician names, and Parkinson disease symptoms beforehand. We will keep the information obtained during the interview process indefinitely unless you choose to withdraw from the Registry (see below). We will ask for updates to both your biographical and medical information every year. This will ensure that we have the most up-to-date information on file. These one-year updates can be done by mail-in questionnaires or over the phone. Operation of the Registry: An Executive Board will review all requests to use the Registry. The main function of the Executive Board, which consists of researchers from the University of Washington and the VA Puget Sound Health Care System, is to make sure that only quality studies are allowed to utilize the Registry. The Registry is also overseen by an Advisory Board which consists of representatives from the American Parkinson Disease Association, Northwest Parkinson's Foundation, and Northwest Collaborative Care. Once a suitable research study arises, we will contact you either by mail or email and provide you with contact information for the study's Research Coordinator. If you agree to participate in any study, you will be asked to sign a specific consent form that describes that particular study in detail. Certain studies may not appeal to you. You are free to decide not to participate in any study and remain in the Registry. You are encouraged to call us at any time if you have questions or concerns about your participation in a particular study. Some of the information obtained from your participation in other research studies will be given back to us and we will store this information in your Registry records. We will take a number of measures to ensure the confidentiality of this transferred information. Information given to us by outside research groups will not be available to you through the Registry. You may inquire about this information directly by contacting the research group that conducted the study. RISKS, STRESS, OR DISCOMFORT During the interview process, you may feel uncomfortable answering some questions. You may skip any question that you do not want to answer. We will make sure that the entire interview process is as stress-free as possible. If you choose to provide personal information on our website, there is a risk that your information may be viewed by unauthorized users. If you participate in other research studies, those researchers will protect the privacy of the information they collect about you. However, there is always a risk that someone could find out that you are a research participant and could learn private information about you. BENEFITS OF THE STUDY We do not expect you to directly benefit from being in this study. However, the facilitation of research studies and the improved access to these studies might provide future benefits to individuals with Parkinson disease and related disorders. OTHER INFORMATION Security Measures: Your confidentiality is one of our primary concerns. All telephone interviews are conducted in a secure private office. Information obtained in the Registry will be accessible only to those individuals and groups listed in this form. All of your research records will be kept in locked cabinets and protected computer files. Your information will never be given or sold for advertisement or fund-raising. If you choose to submit personal data on the Registry website, there is a risk that your information may be viewed by unauthorized users. However, we use security measures to minimize the risk to you. These measures include encrypting information during the transmission from your web browser to the Registry server and keeping encrypted identifiable information separate from coded research data. The server is secured in a locked room with access limited to Registry staff. We will not place your name on any research data. Instead, we will assign a code number to your information. We will keep the master list that links your name to your code number in a locked cabinet. We will not share your information with anyone unless you ask us to. The only exception is if there is a risk of possible harm to others or to yourself. Your name will not appear in any reports about the Registry. All information and results from the Registry will be kept indefinitely unless you withdraw from the Registry. Alternatives To Takeing Part In This Study: Being in this study is voluntary. This is not a treatment study. You can decide not to be in the study. Your decision to participate will in no way affect the quality of your health care, and there will be no penalty or loss of benefits to which you are otherwise entitled. Over-sight Committees: In some cases, the following people or groups might ask us to review our records to make sure that we are following all the regulations properly: • The VA committees that oversee research, including the Institutional Review Board that oversees the safety and ethics of VA studies. • Seattle Institute for Biomedical and Clinical Research (SIBCR). SIBCR is the nonprofit institute that works with the VA to conduct research and administers our research funds. • Other government oversight agencies that oversee research, such as the Department of Veterans Affairs, Department of Health and Human Services, and National Institutes of Health. Withdrawing from the Registry: • You can withdraw from the Registry at any time by notifying us in writing. • All information except for your responses to the screening questionnaire form will be deleted. This form will not contain any personal identifying information and cannot be linked to you. For regulatory reporting purposes, we will also retain gender, veteran status, racial and ethnicity information. • Your decision will not affect the quality or level of care provided by your physician. • If we are notified that a Registry subject has died, we will retain all of his/her information for regulatory reporting and statistical purposes. If a legally authorized representative requests to remove information, we will remove personal identifying information and retain responses on the screening questionnaire form, as well as gender, veteran status, racial and ethnicity information. • If a legally authorized representative requests to remove information, we will remove personal identifying information and retain responses on the screening questionnaire form, as well as gender, veteran status, racial and ethnicity information. For Subjects Participating in Other PD Studies: If you are a current participant in Parkinson disease-related studies conducted here at the University of Washington (UW) and Seattle VA Medical Center (Alzheimer's Disease Research Center: Participant Registry and Sample Repository, The PaGeR Study, or PANUC Clinical Core and Data Management) we are asking you to give us verbal consent in order to obtain the following: • Your permission to provide the Registry with personal information: Name, date of birth, home address, phone number, sex, ethnicity/race, email address if applicable, and legally authorized representative's contact information if applicable. • Your permission to transfer your medical information from the above mentioned studies to the Registry: Information about your Parkinson disease or related disorders such as age and year of first symptoms, age and year of diagnosis; current symptoms, Hoehn & Yahr stage; results of available tests related to Parkinson disease (e.g. Unified Parkinson's Disease Rating Scale (UPDRS), Mini-Mental State Examination (MMSE), neuropsychological testing data, depression scales, sleep scales/studies); use of, response to, and complications from anti-Parkinson medications; family history of Parkinson disease and related disorders; and relevant medical/surgical history (e.g., history of deep brain stimulator placement, low blood pressure, and damage to nervous system outside the brain or spinal cord). • Your permission to provide the Registry with yearly personal and medical updates • Your permission to be contacted for future research studies If updates to your research records occur after we transfer your information to the Registry, we might also transfer this updated information to the Registry whenever this occurs. Other: • You will not be paid or otherwise receive compensation for taking part in the Registry. • If you have any questions regarding the diagnosis or treatment of your disease, we can refer you to the appropriate agencies (e.g., American Parkinson Disease Association, Northwest Parkinson's Foundation) that can provide lists of support groups and physicians in your area. • We will not provide any medical advice. • Information generated by utilizing this Registry may be published in medical literature or used for medical education. Your identity, however, will never be included. • If you choose to be informed of updates and studies by email, we cannot guarantee the confidentiality of this information. SUBJECT'S STATEMENT This study has been explained to me. I volunteer to take part in this research. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the researchers listed on page 1 of this form. If I have questions about my rights as a research subject, I can call the Human Subjects Division at (206) 543-0098. I will retain a copy of this information statement.


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