Please carefully read the statements below (or have them read to you) and think about your choice. No matter what you decide it will not affect whether you can be in the research study, or your routine health care [Choose or for each statement by inserting your initials “Yes” “No” on the line]. a) I agree to have extra [SPECIFY SAMPLES] drawn during this study specifically for long term storage and future use. Yes _________ No_________ b) I give permission for my [SPECIFY SAMPLES] to be stored and used in future research but only on the same subject as the current research project: [give name of current research project] Yes _________ No_________ c) I give permission for my [SPECIFY SAMPLE] to be stored and used in future research of any type (excluding genetic research) which has been properly approved by Pharma-Ethics Research Ethics Committee. Yes _________ No_________ e) I to have samples of my [SPECIFICY SAMPLE] stored in South Africa after this study has ended and used for future testing related to [SPECIFICY CONDITION]: Yes _________ No_________ f) I agree to have my [SPECIFY SAMPLE] shipped to laboratories outside South Africa for tests required for future studies that have been approved: Yes _________ No_________ CONSENT STATEMENT: By signing I agree that:
Please carefully read the statements below (or have them read to you) and think about your choice. No matter what you decide it will not affect whether you can be in the research study, or your routine health care [Choose “Yes” or “No” for each statement by inserting your initials on the line]. a) I agree to have extra [SPECIFY SAMPLES] drawn during this study specifically for long term storage and future use. Yes _________ No_________ b) I give permission for my [SPECIFY SAMPLES] to be stored and used in future research but only on the same subject as the current research project: [give name of current research project] Yes _________ No_________ c) I give permission for my [SPECIFY SAMPLE] to be stored and used in future research of any type (excluding genetic research) which has been properly approved by Pharma-Ethics Research Ethics Committee. Yes _________ No_________ e) I to have samples of my [SPECIFICY SAMPLE] stored in South Africa after this study has ended and used for future testing related to [SPECIFICY CONDITION]: Yes _________ No_________ f) I agree to have my [SPECIFY SAMPLE] shipped to laboratories outside South Africa for tests required for future studies that have been approved: Yes _________ No_________ CONSENT STATEMENT: By signing I agree that:
PARTICIPANT%20INFORMED%20CONSENT%20FOR%20OPTIONAL%20STORAGE%20AND%20FUTURE%20SAMPLES%20OF%20UNUSED%20SAMPLES-%20Template.docx