17. Who will be authorized to collect, use and disclose to otfbrs your protected health
 iiformalion?

 Your prolecled health r-formation may be collected, used, and disclosed to others by

 the study Principal Investigator. Patricia A. McNalty
 Dr. Peer Gearan, ChairnmuL Depanmenl of Onhopedii Shands at UF
 ohir professionals oa the University of Florida or Shands Hospital thai provide study-
 related ratment or procedures
 The Univesity of Forida Institutional Review Boad



I1 Once collected or used, who may your projected health information be disclou-d lo?


 SUS and foreign goviermenual aSencs who are responsible for overseeing reach,
 such as the Food ad Drug Adrmnistration. the Department of Heakh and Human
 Services, and the Oilice ojF Huan Research Prolcclbons
 Government agencies who are responsible for overseeing public health cones such
 as the Centers for Disease Cotrol and Federal, State ad local health departments


19. Ifyou agree to partlcipale ln bis research, bow lo will your protected health
 information be collected, used and disclmed?

 Your projected heallh inbrnmaion will be used and disclosed forever.



20. Why are you being lasdt roe turhorhz Ihe collection, use mad disclosure to orher afyour
 protected health inornmalion?

 Under a new Federal Law, researches cannot collect, u.e or djsclor any ofyoa prolclicd
 heacih [nifmu ion for research unless you allow them to by signing this canse arJ
 authorizarion.

21. Are you required to sign this content and authorizatin and allw the researchen to
 collect, use and discose (give) to others ofyour protected health information?

 No. and voLr reiual ro sign wilm nt alffcl yor Ircalnmeni, payment, oero1Mb nl, or eliibilty
 for any benefits outside this research study. fHoiver, you cannot participate In tis research
 unless you allow rhe collection, use ard dtscairir'e iftyrir protected he lth mrobrowaion bi
 signing shis cwfasendmfrkorlaftio


259-2003 / 07-10-03 / Page 5 of 7