Night Eating Questionnaire - Terms of Use

By checking the "agree" box on the night eating questionnaire, you are agreeing to allow the study investigators to use your survey responses for a study of people's responses to the Night Eating Questionnaire and to determine eligilibility for studies of the Night Eating Syndrome .  Please complete the questionnaire even if you are not interested in any further studies.  If you are interested, please reply to the e-mail that will be sent to you at the completion of the survey, and the study investigators will contact you regarding participation in a study. Results of all tests and procedures done are solely for this research study and not as part of your regular care; they will not be included in your medical record unless you request otherwise.

By agreeing you are permitting the University of Pennsylvania Health System (UPHS) and the Perelman School of Medicine (SOM) to use your personal health information for research purposes. The information you enter here will only be used within the UPHS and the SOM.

The following personal health information will be collected and used for research purposes.

• Name
• Address
• Telephone number
• email address
• height, weight, heaviest weight
• age
• symptoms of the night eating syndrome

The following individuals and organizations may use your personal health information for this research project:

• The Principal Investigator and the Investigator's study team (other University staff associated with the study)
• The University of Pennsylvania Institutional Review Boards (the committees charged with overseeing research on human subjects) and University of Pennsylvania Office of Regulatory Affairs
• The University of Pennsylvania Office of Human Research (the office which monitors research studies)
• Authorized members of the University of Pennsylvania and the UPHS and SOM workforce who may need to access your information in the performance of their duties

The Principal Investigator or study staff will inform you if there are any changes to the list above during your active participation in the trial.

No one outside the SOM or UPHS will have access to any information that could identify you by name.

Your authorization for use of your personal health information for this specific study does not expire . This information may be maintained in a research repository (database). However, UPHS and SOM may not re-use or re-disclose your personal health information collected in this study for another purpose other than the research described in this document unless you have given written permission for the Principal Investigator to do so. However, the University of Pennsylvania Institutional Review Board may grant permission to the Principal Investigator or others to use your information for another purpose after ensuring that appropriate privacy safeguards are in place.

You may withdraw your permission for the use and disclosure of any of your personal information for research, but you must do so in writing to the Principal Investigator at the address on the first page (http://www.med.upenn.edu/weight/contact.shtml.) Even if you withdraw your permission, the Principal Investigator for the research study may still use your personal information that was collected prior to your written request if that information is necessary to the study. If you withdraw your permission to use your personal health information that means you will also be withdrawn from the research study.