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Thousands of lives are saved every year because women are heeding the call to come for yearly mammograms, and at the institute, we aim to make it easier for them to do so. With earlier detection and treatment methods, we are able to tailor a woman’s breast care to her individual needs. With this in mind, we have created a risk assessment model for the development of breast cancer specific to Northern New Jersey. This was made possible through a grant by the Susan G. Komen Foundation. Please consider being part of our study. HACKENSACK UNIVERSITY MEDICAL CENTER Consent Form You are being asked if you wish to participate in a research study. Your decision to take part in this study is voluntary. If you decide not to participate or if you choose to withdraw after being in the study, you will not lose any benefits associated with your medical care. You are being encouraged to ask questions before deciding whether you wish to participate and at any time during the course of the project. Title of Protocol High Risk Database Sponsor: Hackensack University Medical Center How long will I be in the study? The collection of the data will continue until a total of 2000 participants have completed the high-risk questionnaire. Why is this study being conducted? You are being asked to participate in a research study involving the collection of your personal data and the data of family members. The purpose of this data collection is to develop an accurate database that relates to all actual and potential risk factors related to the development of breast cancer. A risk assessment model specific to our Northern New Jersey population will then be developed based on the data collected. In collecting and evaluating the data we at Hackensack University Medical Center will be better equipped to educate, detect breast cancer in its early stages and treat this disease more effectively. Dear Patient, The Betty Torricelli Institute for Breast Care at Hackensack University Medical Center has been collecting demographic information on all clients seen in the breast center since it opened in 1995. To date the information collected has been used to aid the radiologists in their assessment of mammograms and our surgeons in determining the most appropriate treatment options for our clients. In 1999, Hackensack University Medical Center was awarded a grant by the Susan G. Komen Foundation to develop a risk assessment model for the development of breast cancer specific to our Northern New Jersey population. All clients are being asked to complete a detailed history questionnaire, emphasizing familial, personal and environmental issues associated with an increased risk for breast cancer. This information will be put into a database, which should allow us to develop our own model that reflects actual and potential factors related to the development of breast cancer. All information will be kept confidential to the best of our ability. Please consider completing this questionnaire and returning it in the stamped envelope provided or giving the completed questionnaire to your discharge nurse. Please do not forget to sign, date, and return the consent form as well. If you have any questions regarding the questionnaire you can contact Kathy Kirn, RN at 201-996-4275. Thank you in advance for your time and consideration. Sincerely, The Staff of The Betty Torricelli Institute for Breast Care Click here to retrieve and print the questionaire. (PDF Format 1Meg) |
