0 - Philadelphia College of Osteopathic Medicine

Biopsychosocial Effects Among Coronary Artery Bypass Grafting Patients 70
APPENDIX A
INFORMED CONSENT FORM
TITLE OF STUDY
Health Related Outcomes in Heart Surgery Patients
PURPOSE
To understand how psychological, social, and physical factors may be relate to a person's recovery
from heart surgery.
Due to the nature of the research procedure, some information will be withheld until your participation
is completed. After your participation is completed, you will be given complete details about this
research, and have the opportunity to have any questions answered.
You are being asked to be in this research study because you have undergone "coronary artery bypass
grafting surgery" (referred to as CABG, hereafter).
If you do not complete and sign a Consent Form you cannot be in this study.
INVESTIGATOR(S)
Name: Steven Godin, Ph.D., MPH, CHES, Principle Investigator Department: Department of
Psychology
Address: PCOM, 4190 City Avenue, Philadelphia, PA. 19120
Telephone: (570) 422-3562
Name: Theresa A. Kovacs, Psy.D. Candidate, Responsible Investigator Department: Department of
Psychology
Address: PCOM, 4190 City Avenue, Philadelphia, PA 19120
Telephone: (570) 821-6930
Name: Robert DiTimasso, Ph.D., Co-investigator
Department: Department of Psychology
Address: PCOM, 4190 City Avenue, Philadelphia, PA 19120 Telephone: (215) 871­
6543
Name: Michael Harostock, M.D., Collaborator
Wilkes-Barre General Hospital
Department of Surgery: Cardiothoracic Unit
Address: 545 North River Street, Suite 130, Wilkes-Barre, PA 18702
Telephone: (570) 270-4455
Name: Bryan E. McDonnell, M.D., Collaborator
Wilkes-Barre General Hospital
Department of Surgery: Cardiothoracic Unit
Address: 545 North River Street, Suite130, Wilkes-Barre, PA 18702
Telephone: (570) 270-4455