Thank you for your interest in the WASABI Study! To learn more about the study, please share your contact information and the study team will contact you to share more information about the study and answer your questions. Your participation in this study is voluntary and you and/or your child are not obligated to sign up for this study.
If you have any questions about this form or to learn more about protecting your privacy, please contact the study team at 612-326-4228.
Please indicate if you a guardian or parent of an adolescent, adolescent or adult interested in learning more about the WASABI study. If you are a mental health professional, physician or other professional interested in referring to the study, please indicate Professional
* must provide value
Parent/Guardian
Adolescent (Age 14-17)
Adult Participant (Age 18)
Professional
What is your referred method of communication with study team?
* must provide value
Proofpoint Secure Email
Unsecure Email
Phone Call Communication
Phone Call Communication/Proofpoint Secure Email
Phone Call Communication/Unsecure Email
We look forward to connecting with you, but before we move forward with additional conversations through email, we would like to make sure we consider your privacy protection using this method. Email is generally not a secure way to communicate sensitive or health related information as there are many ways for unauthorized users to access email. To offer the most privacy protection, the University of Minnesota uses a platform called Proofpoint Secure Email. The first time you receive a Proofpoint secure email from our research teams, you will be prompted to set up your personal login to access the communication. If you would rather continue emailing as we are now, you can simply sign our unsecure email authorization form to request that we continue without additional privacy protection.
To get started, please fill out the form below to let us know how you would prefer to communicate with our research team.
To offer the most privacy protection, the University of Minnesota uses a platform called Proofpoint Secure Email . The first time you receive a Proofpoint secure email from our research team, you will be prompted to set up your personal login to access the communication. Please remember your login information.
If you would rather continue with standard email , you can simply choose the "Unsecure Email" option and sign our unsecure email authorization form to request that we continue without additional privacy protection.
Participant First Name
* must provide value
Participant Last Name
* must provide value
Participant Primary Phone Number
* must provide value
Participant Secondary Phone Number (Optional)
Do I have your permission to discuss the study with you via email?
* must provide value
Yes
No
1. Purpose. By signing this form, you are agreeing that we may communicate with you through unsecured emails. This form identifies some of the risks of unsecured emails, provides guidelines for use, and documents your consent.
2. Unsecured Email Risks. Unsecured emails can be inadvertently misdirected by the sender or intentionally intercepted by third parties. The University of Minnesota cannot and does not guarantee the confidentiality of unsecured emails, nor is it responsible for unsecured emails that are lost due to technical failure during composition, transmission and/or storage.
3. Privacy and Confidentiality. Unsecured emails are not a secure method of communication. The content of an unsecured email may be viewed by any person who has access to your email account. Unsecured emails that you send us may be viewed by other staff depending on the nature and timing of your unsecured emails, and may be monitored by the University to ensure appropriate use. Unsecured emails may be viewed by your employer if you are using a work email account. Different University staff may view and process unsecured emails depending on the time of day you send them, or when your typical point of contact is not available. Communication by phone, postal mail, and secure email are considered secure. You should consider using these forms of communication.
4. Content. Unsecured emails should be used only for non-sensitive and non-urgent issues. You should limit the amount of health information in your unsecured emails to us to the minimum necessary.
5. Ending Unsecured Email Communication. This authorization does not have an expiration date. We may discontinue using unsecured emails as a means of communication with you by notifying you by unsecured email or letter. You may discontinue using unsecured emails as a means of communication by notifying us, by e-mail to privacy@umn.edu or by letter to:
Health Information Privacy & Compliance Office
410 ChRC (MMC 501)
426 Church Street SE
Minneapolis, MN 55455.
6. Authorizing Signature. I am the research participant or personal representative authorized to act on behalf of the participant. I have read and understand the information regarding guidelines for unsecured email correspondence and had any questions answered to my satisfaction. By signing and providing my contact information below, I agree to communicate by unsecured emails using the email address below:
Participant Email
* must provide value
Please share your contact Information
Please share your parent's contact Information. The WASABI study team will contact your parent to discuss your interest in the study.
Parent's First Name
* must provide value
Parent's Last Name
* must provide value
Parent's Primary Phone Number
* must provide value
Parent's Secondary Phone Number (Optional)
Do we have your permission to discuss the study with you via email?
* must provide value
Yes
No
1. Purpose. By signing this form, you are agreeing that we may communicate with you through unsecured emails. This form identifies some of the risks of unsecured emails, provides guidelines for use, and documents your consent.
2. Unsecured Email Risks. Unsecured emails can be inadvertently misdirected by the sender or intentionally intercepted by third parties. The University of Minnesota cannot and does not guarantee the confidentiality of unsecured emails, nor is it responsible for unsecured emails that are lost due to technical failure during composition, transmission and/or storage.
3. Privacy and Confidentiality. Unsecured emails are not a secure method of communication. The content of an unsecured email may be viewed by any person who has access to your email account. Unsecured emails that you send us may be viewed by other staff depending on the nature and timing of your unsecured emails, and may be monitored by the University to ensure appropriate use. Unsecured emails may be viewed by your employer if you are using a work email account. Different University staff may view and process unsecured emails depending on the time of day you send them, or when your typical point of contact is not available. Communication by phone, postal mail, and secure email are considered secure. You should consider using these forms of communication.
4. Content. Unsecured emails should be used only for non-sensitive and non-urgent issues. You should limit the amount of health information in your unsecured emails to us to the minimum necessary.
5. Ending Unsecured Email Communication. This authorization does not have an expiration date. We may discontinue using unsecured emails as a means of communication with you by notifying you by unsecured email or letter. You may discontinue using unsecured emails as a means of communication by notifying us, by e-mail to privacy@umn.edu or by letter to:
Health Information Privacy & Compliance Office
410 ChRC (MMC 501)
426 Church Street SE
Minneapolis, MN 55455.
6. Authorizing Signature. I am the research participant or personal representative authorized to act on behalf of the participant. I have read and understand the information regarding guidelines for unsecured email correspondence and had any questions answered to my satisfaction. By signing and providing my contact information below, I agree to communicate by unsecured emails using the email address below:
Parent's Email Address
* must provide value
First Name
* must provide value
Last Name
* must provide value
Primary Phone Number
* must provide value
Secondary Phone Number (Optional)
Do we have your permission to discuss the study with you via email?
* must provide value
Yes
No
1. Purpose. By signing this form, you are agreeing that we may communicate with you through unsecured emails. This form identifies some of the risks of unsecured emails, provides guidelines for use, and documents your consent.
2. Unsecured Email Risks. Unsecured emails can be inadvertently misdirected by the sender or intentionally intercepted by third parties. The University of Minnesota cannot and does not guarantee the confidentiality of unsecured emails, nor is it responsible for unsecured emails that are lost due to technical failure during composition, transmission and/or storage.
3. Privacy and Confidentiality. Unsecured emails are not a secure method of communication. The content of an unsecured email may be viewed by any person who has access to your email account. Unsecured emails that you send us may be viewed by other staff depending on the nature and timing of your unsecured emails, and may be monitored by the University to ensure appropriate use. Unsecured emails may be viewed by your employer if you are using a work email account. Different University staff may view and process unsecured emails depending on the time of day you send them, or when your typical point of contact is not available. Communication by phone, postal mail, and secure email are considered secure. You should consider using these forms of communication.
4. Content. Unsecured emails should be used only for non-sensitive and non-urgent issues. You should limit the amount of health information in your unsecured emails to us to the minimum necessary.
5. Ending Unsecured Email Communication. This authorization does not have an expiration date. We may discontinue using unsecured emails as a means of communication with you by notifying you by unsecured email or letter. You may discontinue using unsecured emails as a means of communication by notifying us, by e-mail to privacy@umn.edu or by letter to:
Health Information Privacy & Compliance Office
410 ChRC (MMC 501)
426 Church Street SE
Minneapolis, MN 55455.
6. Authorizing Signature. I am the research participant or personal representative authorized to act on behalf of the participant. I have read and understand the information regarding guidelines for unsecured email correspondence and had any questions answered to my satisfaction. By signing and providing my contact information below, I agree to communicate by unsecured emails using the email address below:
Email
* must provide value