use the information ih.at yoi corr1pFl)cd using ihe qluisiornaires, pain scores, pain medicine -
 and oilier information oblained from your medical record. If you refuse to let ihe Principal
 Invesligalor continue to keep and use this inirmialion, it will not be used.


13e. Can the Principal In cstnigitor withdraw you from this research srudy?

 You may be u ihdrain from the study without your consent for the following reasons:

 SYou did not qualify to be in dIe study because you do not meet the study
 requirements. Ask the Principal Invesligaor i you would like more infonnmaion
 about this.


14. How will your privacy and the confdenlela.lly of your prrretrld health infnrmalWnh be
 prot ictd?

 Data will be gathered and maintained using confidential codes to protect your identity. Patricia
 McNally. the Principal Ir' scligpor. will gather medical data obtained from your medical
 record. All dala and information will be kepl in a locked rile in the police ofPaTui ciE McNlly,
 I|Lu Pnricipal [vestigator, Patiicia TlMcNall dill assign all confidential code numbers. Access
 to your Fle will be restricted Io ihe Principal Investigator,

 if you participate in this research, your protected health information will he co lkl.-d. used, and
 disclosed under the te=s specified in secions 15 24 below.


15. If you agree o participate in Ib s research slud). bhat proiLert-d hea lh idfornArian
 about you may be coUeted, used and disclosed to others?

 To dLirreir Lc ui c! igibili Ly if the sIudy and as paIr oI your participation in the study, your
 prolected heallh infrmnalion that is obtained from you, fro review of your past, cuarcn or
 future health rcconls, from procedures such as physical examinalions, x--nys, blood or urine
 less or other procedures, rom your response to any study treatments you receive, from your
 study visits and phone calls, and any oLliier asudy rriar-d IL akh information, maybe collected,
 used and disclosed to others. More specifically, tie following in frunritiion ma y bK collecled,
 used, and disclosed to others:

 Complete past medicaL history to dalerninc eligibility criteria listed in informed
 consent
 Questioniaires that you have completed
 SIMcdical rc-rd 1 aboful yourjoint replacement surgery
 SMedical records about pain niedcalion use after surgery
 SMedical records about pain reporlcd
 Medical records about anesthesia used during surgery


259-2003 / RcV 01-21-.4 I'Pac 4 of 7