HIPAA Authorization:

By agreeing to take this survey, you authorize VCU and VCU Health to use and/or share your health information for this research. The health information just described may be used by and/or shared with the following people and groups to conduct, monitor, and oversee the research: the Principal Investigator and Research Staff, Institutional Review Boards, Government/Health Agencies, and Others as Required by Law. Once your health information has been disclosed to anyone outside of this study, the information may no longer be protected under this authorization. This authorization will expire when the research study is closed.

You may change your mind and revoke (take back) the right to use your protected health information at any time. Even if you revoke this Authorization, the researchers may still use or disclose health information they have already collected about you for this study. If you revoke this Authorization you may no longer be allowed to participate in the research study. To revoke this Authorization, you must write to the Principal Investigator: Jessica LaRose, Box 980149, 830 East Main Street 4th floor, Richmond VA 23219.

If you're interested in participating and willing to answer these questions online through this secure website, please click yes below.

If you prefer to answer these questions in person or over the phone, or have questions about this research, please contact Jessica LaRose at 804-628-7521, or jessica.larose@vcuhealth.org.

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