CONSENT TO PARTICIPATE IN THE RESEARCH PARTICIPANT REGISTRY (Pitt+Me)

What is the purpose of this Research Registry? A research registry is a collection of individuals interested in being
told of research studies of which they might like to take part. Part of UPMC’s mission is to provide outstanding
patient care by learning from research studies. Because you are a patient at a UPMC facility age 18 or older, we are
inviting you to participate in this research registry.

How does this registry work? If you join the registry, you will be giving your permission:
(1) for UPMC and University of Pittsburgh researchers to use all of your past, current and future medical record
information for retrospective research studies or to see if you are eligible for any research studies, and
(2) to allow members of the Research Participant Registry Office to contact you to find out if you are interested in
learning about research studies for which you appear to qualify. This office will also send you periodic mailings that
will provide you with educational information about health, about interesting research findings, and about research
studies that are available. Some of these studies are clinical trials, which are research studies looking at new ways to
diagnose, prevent, or treat medical diseases or disorders. Some of these research studies may have something to do
with a disease or condition that you have, and some studies will need healthy individuals to participate. You do not
have to participate in any research study that you hear about as a member of the registry.

How will the privacy of my medical record information be protected? Several procedures have been put into place
to protect the privacy of your medical record information. Only members of the Research Participant Registry Office
and staff in the Research Conduct and Compliance Office will have access to your identifiable medical record
information, and these individuals will be required to sign a privacy agreement. However, just as with the use of
your medical information for health care purposes, we cannot guarantee its privacy.

Are there any risks or benefits associated with participation? There are no physical risks associated with agreeing
to participate in this registry. There is a possibility of a breach of confidentiality, as described above, but we have
safeguards in place to minimize that. There may be no direct benefits to you, but Registry participants will have
access to educational information regarding their health. There are no costs or payments associated with
participation in this Registry.

May I withdraw, at a future date, my permission for participation in this Research Registry? Yes. To do so, you
can contact the Research Participant Registry Office by phone (1-866-438-8230), or at the address listed above.

Your participation is completely voluntary and your decision whether or not to participate in this Registry, or to later
withdraw from it, will not affect your current or future medical care at UPMC. Your medical record information will
be reviewed until you withdraw your permission for participation in this registry.

If you would like additional information, you may contact the Research Participant Registry Office at 1-866-438-
8230. Questions about your rights as a research participant will be answered by the Human Subject Protection
Advocate at the University of Pittsburgh IRB Office (1-866-212-2668).

I do wish to be included in the UPMC Research Registry and agree to allow the use and disclosure of my
medical record information, as described above.

University of Pittsburgh STUDY19090273 Approved: 04/25/2025 Expires: 05/08/2026