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Self-Screening

Screening Questionnaire

This information was created by the ROSETA Leeds Clinical Trials Research Unit (CTRU) trial team. We are carrying out the ROSETA Optimisation study, which is ethically approved research in the public interest. As part of this, if you are interested in taking part, we will ask you to answer some brief questions to determine whether this study might be suitable for you.

It is important that you know the following things about how your information will be used if you complete this questionnaire. Click on each header to find out more.

We would like to collect your full name, phone number, email address and postcode.

This is so we are able to inform you whether you are suitable or not to take part in ROSETA. Your postcode will allow us to confirm whether a participating hospital is close to you.

This study and collection of this data has been approved.

Collection of this data has been approved by the Yorkshire & The Humber – South Yorkshire Research Ethics Committee. The University of Leeds are responsible for what data is collected, what it is used for and making sure it is used correctly and legally.

The Leeds Clinical Trials Research Unit (CTRU) will have access to the information you submit in this questionnaire.

Staff at the Leeds CTRU will be able to see the answers you provide to the screening questions.

The CTRU will use your contact details to let you know whether you are suitable to take part, and if so, we will securely send your details to your local hospital research team.

The contact details you give us will only be used to contact you about potentially taking part in ROSETA. Both your local hospital research team and the Leeds CTRU will contact you.

We will not use your contact details submitted in this form for any other purpose than contacting you to discuss taking part in the ROSETA study.

If you are potentially eligible for the study after answering the screening questions, we will share your data with the participating hospital that you choose from the list provided for the purpose of them arranging a call with you to discuss the study further.

We are only collecting the data we need to check you are potentially suitable to take part in the study, and to be able to contact you to let you know if you are suitable to take part.

We will collect answers to specific questions to check whether you could be suitable to take part. You will be asked to select your local hospital from a list or provide your local hospital name if it is not listed. We will only collect data that we need to be able to determine if you are likely to be suitable to take part, to contact you to let you know the outcome and to discuss the study further.

The data we collect will be stored securely on an online database called REDCap. After 3 months we will securely destroy the identifiable data you have entered in this questionnaire.

The identifiable data you submit in this questionnaire will be held for a maximum of 3 months. After 3 months we will remove your name, phone number, email address and postcode from this database. We might still have these details if you have gone on to take part in the study. If you take part in the study, your data will be stored as per the Participant Information Sheet for a minimum of 5 years.

We will not share your data with anyone other than ROSETA researchers.
Please only complete this questionnaire if you are interested in this study.

You will not be able to tell us you are not interested in this questionnaire.

You will not be able to delete, remove, access or amend some of the data you enter into this questionnaire.

You can ask us to remove your identifiable details from the data in this database (this means your name, phone number, email address and postcode). Please contact ROSETA@leeds.ac.uk if you would like this to happen. If you do this, it might mean you can no longer take part in the ROSETA study because we would have no way of contacting you.

The other information you enter can’t be deleted, removed, or amended once it’s been entered, and your rights to access it will be limited. This is the information about you, your health and your access to computers or devices. We need to keep this information so that we have a complete picture of who considered taking part in ROSETA. This is an important part of the permanent, public record of this clinical trial. It will allow researchers, regulators and patients to see how the trial was run.

However, once your name is no longer stored with this information, there will be no way of anyone knowing it is about you. No details that could identify you would ever be made public without your consent.
We will always treat all data we have extremely carefully, and make sure we comply with all aspects of the laws about data protection.

Questions?

If you have any questions about how your data are used, or would like to report a problem, please contact the University of Leeds Data Protection Officer:

  • Email: DPO@leeds.ac.uk
  • Postal address for data protection issues: University of Leeds, Room 11.72 EC Stoner Building, Leeds, LS2 9JT
  • Telephone number: +44 (0)113 243 1751

For more information about how data are used at the Leeds Institute of Clinical Trials Research and who to contact in case of a problem, please go to https://ctru.leeds.ac.uk/privacy/.


Please click HERE to complete the
Screening Questionnaire