team to give you a form to revoke the authorization. Your request will be valid when the Release of Information Office receives it. If you revoke this authorization, you will not be able to continue to participate in the study. This will not affect your rights as a VHA patient to treatment or benefit outside of the study. If you revoke this authorization, [insert name of Site Investigator] and his or her research team can continue to use information about you that was collected before receipt of the revocation. The research team will not collect information about you after you revoke the authorization. Treatment, payment or enrollment/eligibility for benefits cannot be conditioned on you signing this authorization. This authorization will expire at the end of the research study unless revoked prior to that time. WILL MY INFORMATION BE USED FOR RESEARCH IN THE FUTURE? [If the research involves the collection or use of identifiable private information or biospecimens, insert one of the following:] or specimens [collected from you] for this research may be used for future research “Information studies or shared with other researchers for future research. If this happens, information which could identify you will be removed before any information or specimens are shared. Since identifying information will be removed, we cannot ask for your additional consent. [If is possible (i.e. more than a theoretical risk), insert a statement to that effect and describe any risks].” OR or specimens collected from you will not be used for future research studies or shared “Information with other researchers for future research. [If the research involves the storage and maintenance of identifiable private information or biospecimens for future use, please ensure the following are addressed: proposed use, collection and storage procedures, procedures for oversight of security and maintenance, who will have access, procedures to protect confidentiality, procedures for withdrawal, etc.] [If specimens may be used for commercial profit, insert the following:] Specimens collected from you for this research may be used to develop products which could be sold in the future. The investigator does not plan to share any profits or losses from the sale of those products with you.”
team to give you a form to revoke the authorization. Your request will be valid when the Release of Information Office receives it. If you revoke this authorization, you will not be able to continue to participate in the study. This will not affect your rights as a VHA patient to treatment or benefit outside of the study. If you revoke this authorization, [insert name of Site Investigator] and his or her research team can continue to use information about you that was collected before receipt of the revocation. The research team will not collect information about you after you revoke the authorization. Treatment, payment or enrollment/eligibility for benefits cannot be conditioned on you signing this authorization. This authorization will expire at the end of the research study unless revoked prior to that time. WILL MY INFORMATION BE USED FOR RESEARCH IN THE FUTURE? [If the research involves the collection or use of identifiable private information or biospecimens, insert one of the following:] “Information or specimens [collected from you] for this research may be used for future research studies or shared with other researchers for future research. If this happens, information which could identify you will be removed before any information or specimens are shared. Since identifying information will be removed, we cannot ask for your additional consent. [If is possible (i.e. more than a theoretical risk), insert a statement to that effect and describe any risks].” OR “Information or specimens collected from you will not be used for future research studies or shared with other researchers for future research. [If the research involves the storage and maintenance of identifiable private information or biospecimens for future use, please ensure the following are addressed: proposed use, collection and storage procedures, procedures for oversight of security and maintenance, who will have access, procedures to protect confidentiality, procedures for withdrawal, etc.] [If specimens may be used for commercial profit, insert the following:] Specimens collected from you for this research may be used to develop products which could be sold in the future. The investigator does not plan to share any profits or losses from the sale of those products with you.”