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Information
You have expressed that transportation is a barrier to your participation in research activity or memory screening. Due to this, we are offering the opportunity to take part in our transportation services program to allow for you to attend your scheduled research-related appointments with Axiom Brain Health LLC.
What is the purpose of this consent?
The purpose of this consent is to offer transportation services to and from your scheduled research appointments with Axiom Brain Health (ABH).
How long can I take part in the ABH transportation services?
You will be able to utilize this service for appointments set up by the Axiom Brain Health team related to participation in research studies. If you participate in a research study that offers its own transportation services, you will be provided the information and/or consent to do so under the research study. The staff at ABH will provide more information about the other transportation services as they present themselves.
What will happen if I choose to take part?
If you choose to take part in the ABH transportation services, you will be asked to sign this consent form. Following, the study staff will provide minimal-necessary personal information (name, phone number, address, date, and time for transportation as well as any special services, such as wheelchair accessibility) to the transportation service (Lyft or other contracted transportation services). No additional information about you or your health will be disclosed to the company.
All contacts with the transportation service will be noted in your Axiom Brain Health participant record.
All information that you provide Axiom Brain Health will be maintained in a secure system with limited access. Only Axiom Brain Health employees and/or auditors will have access to your information on an as needed basis. Your personal information will not be disclosed for any other purpose without your authorization.
Will my information be shared with other third-party services?
If there are any additional services being offered, you will be asked to provide consent/approval to do so prior to any of your personal information being shared with any third-party services or partners. If you decline, no additional information will be shared.
What are the risks?
There is a risk of loss of confidentiality as the service will be aware that you will be going to a research appointment. There are procedures in place to minimize any loss of confidentiality risk. There is no additional medical risk or risk to your study participation if you take part in this service.
What are the benefits?
If you take part in this service, you will not need to worry about making your own transportation arrangements to and from your ABH appointments unless you would prefer otherwise.
What other options are available?
This program is completely optional. If you would like to use your own transportation or transportation services, you are more than welcome to do so. Taking part in a visit with Axiom Brain Health is also optional. If you do not feel comfortable doing so, you can make the decision to cancel your appointment at any time. You also may choose to cancel your consent for transportation services at any time.
What happens if I am injured or harmed during my transportation?
Axiom Brain Health and the transportation services do not take on any liability for any health issues or medical conditions that may arise during transportation to and from ABH’s scheduled appointments.
What if I decide to stop taking part in the transportation service?
If you decide to stop taking part in the transportation service, you will need to inform the Axiom Brain Health study staff so they can make note of this. Any information that was previously shared will not be able to be removed, but no additional information will be shared with the transportation service.
How will I know what service will be used?
You will be informed of the transportation service that will be used prior to your scheduled appointment. If there are any changes, you will be notified of the changes as the site becomes aware.
How long will this transportation service consent last?
This consent for ABH-provided transportation services does not expire. If a new service is available, you will be provided additional information and the ability to consent to take part before use.
Who is funding this service?
The Global Alzheimer’s Platform Foundation (GAP) is funding the Axiom Brain Health participant transportation services.
Axiom Brain Health LLC is owned and operated by the Global Alzheimer’s Platform Foundation (GAP).
Will this service cost me anything?
You will not be responsible for any costs related to the transportation service being offered.
What if I have questions?
You are encouraged to reach out directly to the Axiom Brain Health staff if you have any questions about the offered transportation services.
Axiom Brain Health
2919 W Swann Avenue Suite 105-A
Tampa, Florida 33609
813-353-9613
By signing below:
I grant permission for Axiom Brain Health LLC and its contracted transportation services to provide non-emergency participant transportation for myself and my study partner, if applicable for my Axiom Brain Health scheduled study appointments.
I assume all risks and hazards related to the transportation being provided. I further release, absolve, indemnify and hold harmless Axiom Brain Health LLC and its contracted transportation representative(s). In case of injury, I hereby waive all claims against Axiom Brain Health LLC and its representative(s) and I likewise release from responsibility all person(s) transporting me and my study partner, when applicable to/from scheduled appointments.
I consent to emergency medical treatment for myself and/or study partner as deemed necessary by Axiom Brain Health LLC and/or its contracted transportation service representative(s). If the injury or illness is life-threatening or in need of emergency treatment, I authorize Axiom Brain Health LLC and/or its contracted transportation service representative(s) to call for emergency personnel.
In addition, I hold Axiom Brain Health LLC and its contracted transportation service representative(s) harmless for any lost personal items. I also understand that I and/or my study partner may be denied transportation services if Axiom Brain Health LLC and/or its contracted transportation service representative(s) deem my behavior or study partners’ behavior inappropriate or unsafe to themselves, the driver, and/or other passengers.