Clinical trial: NCT03819920
Section: Confidentiality
Subsections: Authorization To Use Your Health Information For Research Purposes|What Personal Information Will Be Obtained, Used Or Disclosed?|Who May Use Or Disclose The Information?|Who May Receive Or Use The Information?|When Will My Authorization Expire?

Because information about you and your health is personal and private, it generally cannot be used in this research study without your authorization. If you you agree to participate in the study, it will provide that authorization. The form is intended to inform you about how your health information will be used or disclosed in the study. Your information will only be used in accordance with this authorization form and the informed consent form and as required or allowed by law. Please read it carefully before providing authorization.

Your health information related to this study, may be used or disclosed in connection with this research study, including, but not limited to, your weight and height, your diet, your medications, your physical activity level, your smoking history, personal history of cancer, family history of cancer, and personal risk of developing colorectal cancer.

The following parties are authorized to use and/or disclose your health information in connection with this research study:
- The Protocol Director, Dr. Uri Ladabaum
- The Stanford University Administrative Panel on Human Subjects in Medical Research and any other unit of Stanford University as necessary
- Research Staff: Dr. Timothy Yen, Dr. Sang-Ick Chang, Helene Jernick, Mary Christensen

The parties listed in the preceding paragraph may disclose your health information to the following persons and organizations for their use in connection with this research study:  
- The Office for Human Research Protections in the U.S. Department of Health and Human Services
- The Associate Dean of the Stanford Primary Care Clinics
Your information may be re-disclosed by the recipients described above, if they are not required by law to protect the privacy of the information.

Your authorization for the use and/or disclosure of your health information will end on December 31, 2050 or when the research project ends, whichever is earlier.  
  
  
  
  
Protocol Title: Does knowing one's estimated colorectal cancer risk influence screening behavior?  
WITHDRAWAL FROM STUDY
The Protocol Director may also withdraw you from the study without your consent for one or more of the following reasons:
o Failure to follow the instructions of the Protocol Director and study staff. o The study is cancelled. o Other administrative reasons. o Unanticipated circumstances.
Clinical trial: NCT03819920
Section: Purpose of Research
Subsections: What Is The Purpose Of This Research Study And How Will My Health Information Be Utilized In The Study?

The purpose of this study is to characterize whether receiving information about colorectal cancer influences an individual's likelihood of undergoing colorectal cancer screening. As part of the study, you will be asked to complete a series of brief survey questions regarding your attitudes towards colorectal cancer screening. Some of these questions will involve your health information, but this information will not be linked to your identity. We plan to publish the results of this study when complete.
Clinical trial: NCT03819920
Section: Withdrawal from Study
Subsections: If I Give Authorization, Can I Revoke It Or Withdraw From The Research Later?

If you decide to participate, you are free to withdraw your authorization regarding the use and disclosure of your health information (and to discontinue any other participation in the study) at any time. After any revocation, your health information will no longer be used or disclosed in the study, except to the extent that the law allows us to continue using your information (e.g., necessary to maintain integrity of research). If you wish to revoke your authorization for the research use or disclosure of your health information in this study, you must write to: Dr. Uri Ladabaum, 900 Blake Wilbur MC 5355, Palo Alto, CA 94304  
  
  
  
Protocol Title: Does knowing one's estimated colorectal cancer risk influence screening behavior?