samples in a future study about XXX, YYY and ZZZ. (Explain the types of research for which you are seeking approval. HIPAA requires that the consent be specific about the nature of the future use but this may be in general terms, e.g. pediatric heart disease, genetic diseases.) The information and samples will be given a unique code and will not include information that can identify you. (If a Master List will be kept that links the data or specimens to the subject, include the location lab, special room, repository, registry, or computer database in the next sentence.) Information that can identify you or the blood or urine samples may be kept permanently in a XXXXX (examples include: lab, repository, registry, or computer database) at CHOP or at (outside lab). Only the study doctors and those working with them on this study will be able to see information that can identify you. If you leave the study, you can ask to have the data collected about you removed or the samples destroyed. You can also ask us to remove information that identifies you from the data or samples. If the specimens and data will be de-identified (no link to identifiable information) use the following statements instead. The data and specimens will be stored with a code number that cannot be linked back to you. If you the study, we will not be able to which specimens are yours. The data and specimens will remain part of the research. Please indicate whether you will allow the data or samples to be used for future research by putting your initials next to one of the following choices: _____ (initials) The (data and/or specimens) may be used for this study only. _____ (initials) The (data and/or specimens) may be used for other future research studies. If the data or specimens are shared outside of CHOP, no identifiable information will be included. These statements may require modification depending on the requirements of the study. Consent to Inform Your Doctors of Your Study Participation (OPTIONAL) Please indicate whether you would like us to inform your doctor(s) of your participation in this study. _____ (initials) I request that my doctor(s) not be informed of my participation in this study. _____ (initials) I request that my doctor(s) be informed of my participation in this study. OPTIONAL (include other optional components after the signature page)
samples in a future study about XXX, YYY and ZZZ. (Explain the types of research for which you are seeking approval. HIPAA requires that the consent be specific about the nature of the future use but this may be in general terms, e.g. pediatric heart disease, genetic diseases.) The information and samples will be given a unique code and will not include information that can identify you. (If a Master List will be kept that links the data or specimens to the subject, include the location lab, special room, repository, registry, or computer database in the next sentence.) Information that can identify you or the blood or urine samples may be kept permanently in a XXXXX (examples include: lab, repository, registry, or computer database) at CHOP or at (outside lab). Only the study doctors and those working with them on this study will be able to see information that can identify you. If you leave the study, you can ask to have the data collected about you removed or the samples destroyed. You can also ask us to remove information that identifies you from the data or samples. If the specimens and data will be de-identified (no link to identifiable information) use the following statements instead. The data and specimens will be stored with a code number that cannot be linked back to you. If you the study, we will not be able to which specimens are yours. The data and specimens will remain part of the research. Please indicate whether you will allow the data or samples to be used for future research by putting your initials next to one of the following choices: _____ (initials) The (data and/or specimens) may be used for this study only. _____ (initials) The (data and/or specimens) may be used for other future research studies. If the data or specimens are shared outside of CHOP, no identifiable information will be included. These statements may require modification depending on the requirements of the study. Consent to Inform Your Doctors of Your Study Participation (OPTIONAL) Please indicate whether you would like us to inform your doctor(s) of your participation in this study. _____ (initials) I request that my doctor(s) not be informed of my participation in this study. _____ (initials) I request that my doctor(s) be informed of my participation in this study. OPTIONAL (include other optional components after the signature page)
consent_form_without_hippa_5-9-2018.docx