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Victorian HIV CURE Volunteer Form

Introduction

Thank you for indicating your interest in participating in HIV cure research activities.

There is no cure for HIV, but researchers worldwide are working on different ways to eliminate the virus. By clicking on the "accept" button, you are confirming that you are happy to be listed on the Victorian HIV Cure Research Volunteer Database. This means that you give your consent for some of your contact details to be stored on a secure electronic service. This will also confirm that you are happy to be contacted in the future by researchers looking for volunteers in HIV cure related research.

We will also be collecting data on your Medicare status as some research studies require you to have a valid Medicare card to participate. This will ensure we only contact you about studies you are eligible for/are appropriate for you.

This database has been created by researchers at The Alfred Hospital and The Doherty Institute and endorsed by representatives from the Melbourne HIV Cure Consortium Community Advisory Board.

This sign-up form will take less than 5 minutes to complete.

This project has been approved by Alfred Hospital Ethics Committee.

Do I have to answer every question?

There are some questions that need to be filled out, such as a valid email address so we can contact you for any further HIV cure research opportunities. You can exit the online form at any stage if you change your mind.

Will my information be kept confidential?

Your answers to the questions in this form will be kept strictly confidential. Only researchers working on this project will have access to them. Your data will be stored on a secure password protected database on The Alfred Hospital servers. This database is only accessible to study investigators who must maintain a password protected account to access this information.

You will only be contacted for future research studies that you have indicated you are interested in. Your information will be retained indefinitely. You can opt-out of this database at any stage and have your information securely deleted.

Why should I participate and are there any risks to me?

By filling in this form you are indicating that you are willing to be contacted for future HIV cure research. We are very grateful to people signing on to this database. We do not anticipate any risks to you in completing this form. This database is voluntary, and you are under no obligation to sign on. You can opt-out at any time. To opt-out, please email the research team at the email address listed below.

The lead researcher on this project is Dr Jillian Lau - The Alfred Hospital and The Doherty Institute

You can contact the research team via email or phone:
E: clinresearch@alfredhealth.org.au
T: +61 3 90766908

Further questions or concerns
If you have any complaints or concerns about your participation in the database that the researcher has not been able to answer to your satisfaction, you may contact:

Complaints Officer, Office of Ethics & Research Governance, Alfred Health
E: research@alfred.org.au
T: +61 3 90763619

Please quote the following project ID number: 53/23

Signature:

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Your preferred name:

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Your gender identity:

Female

Male

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Year of birth:

Preferred method of contact:

Mobile phone number (This is an optional contact choice)

All of the above

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Your email address:

Your mobile phone number:

Your current postcode:

Medicare status:
Do you have a medicare card?

* must provide value

Yes

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There are many ways to get involved in HIV CURE research in Melbourne. Different types of studies can help researchers towards a cure for HIV.

Please indicate which of the following studies you are happy to be contacted about:

Online survey

One-on-one interviews or focus groups

Donating a blood sample (50-70mL - 2-3 tablespoons of blood)

Donating blood draw (150mL - 5 tablespoons of blood)

Leukapheresis (a procedure where two needles are inserted into your veins, and blood is removed from your body. Some white blood cells are filtered off, and the other components of you blood, such as red blood cells and plasma is returned to your body. This may take 3-4 hours).

Having a tissue biopsy (a procedure to remove a small piece of your body, this could be gut tissue, or a lymph gland. This is usually done under local anesthetic and may take 1-2 hours)

Interventional studies (a clinical trial where a new drug is tested. This would include multiple study visits and blood tests for monitoring. Each interventional study is different and would be explained in detail with you by the researcher)

All of the above

I would like to receive an emailed copy of the "HIV CURE research updates" newsletter (6 monthly):

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.