*Please indicate to what extent the study participant is able to withdraw specimens collected for the purposes of the study after the specimens have been shipped offsite, and any limitations to the withdrawal: If genetic testing (e.g., gene identification, gene mapping, genomic analysis, DNA screening)’ is selected ‘For in 2.18.18, questions 2.18.25-2.18.31 appear: *Please indicate whether the sample collection for genetic testing is (select all that apply): Optional Mandatory *Describe the planned genetic testing: *Where will specimens be sent (e.g. name & address including country)? *Indicate how long the specimens will be retained: *Describe what will happen to the specimens at the end of that period (e.g., destroyed, returned): *Please indicate to what extent the study participant is able to withdraw specimens collected for genetic testing after the specimens have been shipped offsite, and any limitations to the withdrawal: *Will participants or their family members or their health care providers be informed of any genetic testing results? Yes No If ‘Yes’: *Describe what information will be shared and with whom? *How will consent be obtained to release this information? *Describe whether participants will be given the option of not receiving information about themselves: If ‘No’: *Please explain/justify: If or retained or banked for any future testing’ is selected in 2.18.18, questions 2.18.32-2.18.37 ‘stored appears: *Please indicate whether the sample collection to be stored or retained or banked for any future testing is (select all that apply): Optional Mandatory *Where will the biobank(s)/repositories be located (e.g., name of bank & address including country)? *Where will the associated data be located (e.g., name & address including country)? *Who will be the custodian of the specimens that will be stored or retained or banked for any future testing? *Who will have access to the banked specimens?
*Please indicate to what extent the study participant is able to withdraw specimens collected for the purposes of the study after the specimens have been shipped offsite, and any limitations to the withdrawal: If ‘For genetic testing (e.g., gene identification, gene mapping, genomic analysis, DNA screening)’ is selected in 2.18.18, questions 2.18.25-2.18.31 appear: *Please indicate whether the sample collection for genetic testing is (select all that apply): Optional Mandatory *Describe the planned genetic testing: *Where will specimens be sent (e.g. name & address including country)? *Indicate how long the specimens will be retained: *Describe what will happen to the specimens at the end of that period (e.g., destroyed, returned): *Please indicate to what extent the study participant is able to withdraw specimens collected for genetic testing after the specimens have been shipped offsite, and any limitations to the withdrawal: *Will participants or their family members or their health care providers be informed of any genetic testing results? Yes No If ‘Yes’: *Describe what information will be shared and with whom? *How will consent be obtained to release this information? *Describe whether participants will be given the option of not receiving information about themselves: If ‘No’: *Please explain/justify: If ‘stored or retained or banked for any future testing’ is selected in 2.18.18, questions 2.18.32-2.18.37 appears: *Please indicate whether the sample collection to be stored or retained or banked for any future testing is (select all that apply): Optional Mandatory *Where will the biobank(s)/repositories be located (e.g., name of bank & address including country)? *Where will the associated data be located (e.g., name & address including country)? *Who will be the custodian of the specimens that will be stored or retained or banked for any future testing? *Who will have access to the banked specimens?
CTO-Provincial-Initial-Application-Form_Version-16-2016MAR14.docx