Research Study Form

Research Study: Determination of Genetic Variants with Chronic Lyme Disease 

CONSENT FORM

Taking part in this research study is entirely your choice. If you decide to participate, you will be asked to provide your 23andMe genome (raw data) via email and answer a few questions in this on-line form and offer your consent to participate. No other action on your part is needed. This will allow us to compare as a group those with chronic Lyme disease to a control group. The analysis will be performed with as large a group of individuals with Lyme disease to a control group of equal size. No one will be studied individually. As a participant in this study, your identity, indicated symptoms on the questionnaire, and data relating to this study will be kept confidential and never shared with anyone including other study participants. 

Please read all of the following information carefully. If you have question a regarding this consent form, the study or about your rights, please call NutriGenetic Research Institute at 717-733-2003. Do not sign this consent form unless you understand the information in it and have had your questions answered to your satisfaction. Please print a copy of this form for your records as it has information to which you may wish to refer in the future.

RISKS: There are no risks to you by participating in the study. It’s purely comparing your genetics to a control group who does not have Lyme disease.

COSTS: There are no costs associated with participation.

COMPENSATION: If you decide to participate in this study, you will be provided with a copy of your nutritional genetic report free of charge and will also be provided with the results of the research. You will be able to see how your genetics compare to the entire Lyme group and a control group. 

PRIVACY AND CONFIDENTIALITY: If you agree to take part in this research study, your personal information will not be given to anyone. If you desire, you can change the name of your 23andMe data to a fictitious name, however, we need your real name on this consent form. If you change the name of your 23andMe file, there is absolutely no way anyone would know the genome is from you, if this is a concern for you. Our goal is to know the genetic patterns of a large group of individuals with Lyme as compared to a control group.

DISCLOSING YOUR IDENTIFIABLE HEALTH INFORMATION: At no time will your name or health information be given out. The purpose of the study is to compare the genetics of a large group of individuals dealing with chronic Lyme to a control group. The only information given out in a written report will be the percentage of genetic variants in a group dealing with chronic Lyme to a control group who does not have Lyme. You will be given a copy of the report, and a copy of your measurements to see how you compare to the Lyme group and the control group.