EXHIBIT A- INFORMED CONSENT -

Nutrition Innovations Research Study (#19020802) 

Site principal Investigator: 

Department: 

Address: 

Protocol Title: 

Sponsor(s) 

Paul H. Bennett, PhD, MSW and 

Karen Mayer, PhD, RN 

ROPH - Professional Nursing Practice 

AgeOptions, 1048 Lake Street, #300, 

Oak Park, IL 60301 

708-383-0258; 800-699-9043 

paul.bennett@ageoptions.org 

Nutrition Innovations Research Study 

(#19020802) 

AgeOptions 

Key Information 

You are being invited to participate in the research study of a program evaluation. Research studies answer important 

questions that might help change or improve the way we do things in the future. 

It is hoped that the information we are about to share will tell you about the study and to help you decide whether you 

want to participate. We will be reading this consent to you; please ask any questions you have before telling us that you 

agree to be in the study. 

Receiving help from AgeOptions is voluntary, as well as your participation in the research. You do not have to 

participate in this study portion of this program to receive our help. If you decide not to participate in this study today 

or in the future, again your ability to receive any assistance from AgeOptions or from your healthcare provider which 

could be Rush University Medical Center or Oak Street Health will not change or be affected. 

Purpose of Study 

The purpose of this study is to explore the value of what is called a closed loop referral system and the benefit of 

services provided to you. A closed-loop referral system is one where nurses, social workers and doctors who make 

referrals for programs for you such as meals will know if you received the food or actually went to a dining site. Wealso 

want to find-out if the services provided to you were helpful. 

Funding of this Study 

The study is funded by a grant from the United States Administration on Community Living. 

Cost and Benefit 

There is no cost to participate in this study and you will not receive anything from us regarding your participation in this 

study other than possibly services. However, while the help you may receive is free, you may be asked to donate 

towards the cost of some of the food services. Here again, contributions are voluntary. 

Potential Risks 

Wehave not identified any risks to you in answering our questions. However if at any time you feel uncomfortable 

answering a question, you can decide not to answer the question or just tell us to stop asking our questions. In addition, 

there is always a risk of loss of confidentiality or information about your identity. AgeOptions is taking precautions to 

secure your identity and will not be disclosing this information to anyone beyond the researchers at AgeOptions. 
What you are Being Asked to Do 

As a participant in the study portion of this program, you will be asked some questions now about your health and wellbeing and then we will contact you again in about eight (8) weeks to ask you many of the same and a few additional 

questions. Answering these questions may take between 10 to 15 minutes of your time. These questions will pertain to 

what you think about your health and well-being and your satisfaction with the services you may receive. 

What about confidentiality of your medical information? 

This authorization is voluntary. Rush University Medical Center and its affiliates ("Rush") will not withhold or refuse your 

treatment, payment, enrollment, or eligibility for benefits if you sign this authorization. You do not have to sign this 

authorization, but that means that you cannot be in the study or receive study-related treatment. 

By signing this document, you voluntarily authorize (give permission to) Paul H. Bennett, PhD, Karen Mayer PhD and 

their study team, and other Rush personnel involved with the conduct and review of this study (which may include offsite personnel) to use or disclose (release) health information that identifies you for the study described in this 

document. 

During the study, Paul H. Bennett, PhD, Karen Mayer PhD and their study team, will collect Protected Health Information 

(PHI) about you for the purposes of this research. PHI is your health information that includes your medical history and 

new information obtained as a result of this study. Some of this information will come from your medical record. The 

health information that Rush may use or disclose for this research includes: Name, Address, Gender, Contact 

information including Telephone Number and/Email Address and Age. 

Paul H. Bennett, PhD, Karen Mayer PhD and their study team may share your health information and the results of your 

study-related procedures and tests with people outside of Rush who assist with the conduct and review of this study. 

The persons who receive your health information may not be required by Federal privacy laws to protect it and may 

share your information with others without your permission, but only if permitted by the laws governing them. Your 

health information described above may be used or disclosed to: 

• To the Researcher, Paul H. Bennett, PhD at AgeOptions and Oak Street Health 

• The study Sponsor, United States Administration on Community Living 

• Monitoring agencies such as the Food and Drug Administration (FDA), the National Institutes of Health and the 

Rush Institutional Review Board (IRB). 

While you participate in the study you will have access to your medical record, but Paul H. Bennett, PhD, and Karen 

Mayer PhD are not required to release your study information that is not part of your medical record. Rush is required 

by law to protect your health information, and study records that identify you will be kept confidential. The results of 

study tests/procedures performed as part of this study may become part of your medical record. Any study information 

in your medical record will be kept indefinitely. Your identity will not be revealed on any report, publication, or at 

scientific meetings. 

You have a right to inspect and copy the information to be disclosed with this authorization and you may obtain a copy 

of the information by contacting the office listed above. 

If you no longer want to be in the study and do not want your future health information to be used, you may change 

your mind and revoke (take back} this authorization at any time by writing to Paul H. Bennett, PhD at AgeOptions, 1048 

Lake Street, #300, Oak Park, IL 60301. If the authorization is revoked, you will no longer be allowed to participate in the 

study and previously authorized individuals/entities may still use or disclose health information that they have already 

obtained about you as necessary to maintain the integrity or reliability of the current study. 

This authorization is valid for the entirety of this research study. It will expire upon completion of the study or if you 

revoke (take back) the authorization. 
If you withdraw from this study, the data already collected from you may not be removed from the study records. The 

study doctors and/or study team may ask you whether they can continue to collect follow-up data on you. If follow-up 

information will be requested, you will be asked to sign a separate, consent form before this information can be 

collected. 

Records of participation in this study will be maintained and kept confidential as required by law. You will be assigned a 

participant identifier. A password and encrypted document will be maintained with your name and assigned identifier. 

In a separate password and encrypted document will be your responses to questionnaires. Both of these documents will 

be stored in password and encrypted protected files in Microsoft Office 365 which maintains the files in the Cloud 

Sharing of Results of the Study 

AgeOptions intends to publish the results of our study findings. However, it is important that you know, that no 

personal information about you will ever be shared regarding your participation in this study. 

Questions 

Do you have any questions? Can you tell me in your own words, what you are agreeing to do? 

If you have any questions in the future, you can reach the Manager of this program and coordinator of this project, Paul 

Bennett at 800-699-9043. In addition, we will be happy to send you a copy of what I am reading to you. 

Consent 

Do you agree to participate in this study by answering some questions now and that we may contact you again in 

approximately eight weeks from now? 

If yes, the name of individual and NowPow Identifier number will be recorded in an Excel Spreadsheet with the columns 

to record the following: 

• Name: _______________ 

• Date: _______ NowPow Identifier#; ________ 

If yes, would you like us to send you a copy of the statement which we just read to you? If yes, a column in the same 

Excel Spreadsheet will record that a copy was sent to the individual 

• Enter date only if request is made for a copy: __________ 

For those that give consent, a column in the same Excel Spreadsheet will record the name of the AgeOptions staff who 

obtained consent and the date of consent. 

I have received consent from this individual to participate in the Nutrition Innovations Research Study (#19020802). 

• Name of AgeOptions Staff Who Obtained Consent: _______________ 

• Date Consent was obtained: _______