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					                                        This proxy consent is for research involving greater than
                                        minimal risk. Remove this instruction box and delete all
                                        instructions from the final consent.



Informed Consent of Legally Authorized Representative
(Proxy/Healthcare Surrogate) for Participation in Research and
Authorization to Collect, Use and Share Your Health Information
Information to Consider Before You Consent An Individual To This Research Study

IRB Study # _____________

Researchers at University of South Florida (USF) [add any other institutions involved in the research
here] study diseases and other health problems people may have. Our goal is to try to find better ways
to help treat these health problems. To do this, we need the help of people who are willing to take part
in a research study.

You are being asked to enroll an individual in a research study. Research studies include only people
who choose to take part. This document is called an informed consent form. Please read this information
carefully and take your time making your decision. Ask the researcher or study staff to discuss this
consent form with you, please ask him/her to explain any words or information you do not clearly
understand. We encourage you to talk with your family and friends before you decide to enroll your
loved one in this research study. The nature of the study, risks, inconveniences, discomforts, and other
important information about the study are listed below.
[Include as applicable]
Please tell the study doctor or study staff if you are taking part in another research study.
We are asking you to take part in a research study called:
[Title of study, as it appears on the IRB application, grant/contract, or sponsored protocol. May also be
the short title indicated on the IRB application.]

The person who is in charge of this research study is [Insert PI name]. This person is called the
Principal Investigator. However, other research staff may be involved and can act on behalf of the
person in charge. [If the PI is a student, add the following statement] [He/She] is being guided in this
research by [name of Faculty Advisor].

The research will be conducted at [List the site(s) where the participant will be expected to take part in
the research].

[If the research is not funded by an external source(s), omit the following statement:]
This research is being sponsored for by [insert Sponsor’s name].




IRB Number:                                                               Informed Consent Rev #
IC Proxy RA Template – 2010-09-05                                         IRB Consent Rev. Date:
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Finding the best person to give legally authorized consent:
Under certain circumstances, someone can give consent for another person to take part in research. This
person is the Legally Authorized Representative (LAR) or “participant by proxy.” The LAR can make
choices for the participant, if the participant is not able to make choices for him or herself. A LAR can
be any of the people listed below.
A. In the list below, research staff should write “LAR” in the space next to the description of the person
   who will provide consent and research authorization for the person participating in this research. If
   there is a person with a higher authority, write in the space why that person is not available or able to
   act as proxy. This following is an example:
               Health Care Surrogate: No one was named
               Spouse:                Spouse has died
               Adult Child:           Unable to reach by phone after several tries
               Parent:                   LAR
(1)    Health Care Surrogate named by the research subject: _____________________________
(2)    A guardian of the subject, appointed by the court. He/she must be authorized to give consent to
       research:_____________________________________
(3)    The person's spouse: __________________________________
(4)    An adult child of the subject. If the person has more than one adult child, a majority of
       the adult children who live near enough to be asked:__________________________________
(5)    A parent of the subject: _____________________________________________
(6)    The adult sibling of the subject: _________________________________________________.
(7)    An adult relative of the subject who has shown special care and concern. This adult relative
       has kept in regular contact and knows how the subject feels about things such as research, what
       the person likes to do, what the person’s health is like, what the person believes and thinks is
       right ________________________________________________________________.
(8)    A close friend of the subject: ________________________________________.



Why is this research being done?
[Briefly explain, in plain language, the purpose of the study. Tell the person, in lay terms, how the
research will be carried out. State whether the experimental drug or procedure has been tested in
humans before.]

Should the person for whom you are signing consent take part in this study?
This form tells you about this research study. After reading through this form and having the research
explained to you by someone conducting this study, you can decide if you think the person for whom
you are signing consent [and research authorization] would want to take part in the study. [If this is a
medical intervention study add the following sentence: The person for whom you are signing consent
does not have to take part in this research to receive their regular medical care.]
This form is written as if you, the LAR, were participating in the research. This helps you think in terms

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of what the person for whom you are signing consent would do or what is best for him/her. After reading
through this form, you can decide if you want your loved one to take part.

You may have questions this form does not answer. If you do have questions, feel free to ask the study
doctor or the person explaining the study, as you go along. Take your time to think about the
information that has been provided to you.

This form explains:
    Why this study is being done.
    What will happen during this study and what you will need to do.
    Whether there is any chance of benefits from being in this study.
    The risks involved in this study.
    How the information collected about you during this study will be used and with whom it may be
       shared.

Taking part in this research study is up to you. If you choose to be in the study, then you should sign
this informed consent form. If you do not want to take part in this study, you should not sign this form.

Why are you being asked to take part?
We are asking you to take part in this research study because [Explain, in plain language, the
condition(s) or situation that makes this person eligible for the research. Example: We are asking you
to take part in this study because you have had a heart attack. We want to find out if this treatment will
help people who have had heart attacks.]

What will happen during this study?
[Explain in plain language what will happen during the study. Make sure your explanation addresses
the following: what is being performed as part of the care the participant would normally receive
(standard of care) and what is being performed strictly as part of the research.
For example, include a description of the following:
       Any tests and procedures that will need to be performed, including the purpose of each (for
        example, depression scales, word association tests, and so on). Be sure to briefly explain each
        test or procedure. If there are multiple visits with different procedures occurring at each visit it
        is suggested to list in separate paragraph and/or bulleted items.
       Questions that will be asked and/or interviews/surveys that may be conducted.
       The drug, device, or biologic that you will give the person.
       How much of a dose you will give the person.
       How you will administer the test article to the participant.
       Whether participants’ regular treatment will change if they take and how it will change.
       Whether there are procedures that need to be performed before the research begins. Including a
         washout period, time to quit using other medications, such as over-the-counter drugs or diet
         restrictions.
       How long participants will be asked to stay in the study.
       How often will participants need to come for a research study visit.
       If audio- or videotaping will be used, the participant must be informed of taping and, if

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       applicable, given the option to agree to be recorded. Explain who will have access to these
       tapes, whether the information will be identifiable, how long the tapes will be maintained, and
       how they will be destroyed]

Total Number of Participants
About [number of participants] individuals will take part in this study at USF. [If the study includes
multiple sites, add the following statement] A total of [number of participants] individuals will
participate in the study at all sites.

Alternatives
You do not have to participate in this research study. [This statement is sufficient if there are no
alternatives for the participant.]
Alternatives to participating in the study include: [If there are alternatives, describe the
procedures/treatments/interventions which the participant could receive such as taking a different
course of treatment, etc.]

Benefits
[Use whichever statement is applicable:]
We are unsure if you will receive any benefits by taking part in this research study.
[Or]
The potential benefits of participating in this research study include:
[List and explain any anticipated benefits the person may have from taking part in this study. Please
note that compensation for participation IS NOT considered a benefit.]

Risks or Discomfort
[Use whichever statement is applicable:]
This research is considered to be minimal risk. That means that the risks associated with this study are
the same as what you face every day. There are no known additional risks to those who take part in this
study.
[Or]
The following risks may occur:
   [List and explain the physical, psychological, and social risks/discomforts and when known, indicate
       the relative chances for each.]
   [When applicable, explain any risks that might be associated with a breach of confidentiality,
       including risks to employability, insurability, and/or criminal and civil liabilities.]

Compensation
[IF COMPENSATION FOR PARTICIPATION IS AVAILABLE, include the dollar amount per visit and payment
upon study completion of study activities. Explain any other costs you may be able to remunerate, such
as parking fees, bus or taxi fare; childcare costs, or time away from work.]
You will be paid $$ if you complete all the scheduled study visits. If you withdraw for any reason from
the study before completion you will be paid $$ for each complete study visit.
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[USF investigators must include the following for studies where compensation is more than $50 per
payment or $200 per calendar year. See Research CCHIP # 017 for more information.]
To receive payment, you must provide your social security number, name and address so that we can
comply with IRS (Internal Revenue Service) reporting requirements. When payments are reported to
the IRS we do not tell them what the payment is for, only that you have been paid. If you do not wish to
provide this information you can still take part in this study but you will not be paid.
[If no payment for participation is available, including the following:]
You will receive no payment or other compensation for taking part in this study.
[If commercial development is expected to arise from the study including the following:]
The findings from this research may result in the future development of products that are of commercial
value. There are no plans to provide you with financial compensation or for you to share in any profits if
this should occur.

Cost
[Use only the following statements that apply to your research]
[If the costs of the research are being paid by the study sponsor the following statement is required:]
There will be no additional costs to you as a result of being in this study. However, routine medical care
for your condition (care you would have received whether or not you were in this study) will be charged
to you or your insurance company. You may wish to contact your insurance company to discuss this
further.

[If there are costs associated with the study:]
You or your insurance company, Medicare or Medicaid, will be expected to pay the costs for the
following: [list all procedures which will be the responsibility of the participant outside of routine care.]


Conflict of Interest Statement
[If the Principal Investigator, research staff, or their family members have conflicting interest
associated with this research, insert Conflict of Interest information here. Explain how the conflict will
be managed to ensure that the integrity of the study data. If there is no conflict or potential conflict,
delete this section.]

[The following information can be deleted if you are not part of a covered entity which must adhere to
the HIPAA Privacy Rule Regulations. Otherwise, the following authorization language MUST be
included in your informed consent document.]

Authorization to Use and Disclose Protected Health Information
Who will see your health information?
In this research study, we use and share your health information to the extent authorized (permitted) by
you. We know that this information is private. The federal privacy regulations of the Health Insurance
Portability & Accountability Act (HIPAA) protect your identifiable health information. If you authorize
us to use your information we will protect it as required by the law.
[If the research is being conducted in conjunction with another facility, add the following paragraph.]

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Research at [insert facility name] is conducted jointly with the University of South Florida. By signing
this form, you are permitting [insert facility name] and the University of South Florida to use personal
health information collected about you for research purposes. You are also allowing [insert facility
name] to share your personal health information with individuals or organizations other than USF and
[facility name] who are also involved in the research and listed below.
[If the research is being done solely at USF, add the following paragraph.]
This research is conducted at the University of South Florida (USF). By signing this form, you are
permitting USF to use personal health information collected about you for research purposes within the
USF health care system. You are also allowing USF to share your personal health information with
individuals or organizations other than USF who are also involved in the research and listed below.
Who will disclose (share), receive, and/or use your information?
To conduct this research, USF and the people and organizations may use or share your information.
They may only use and share your information:
      With the people and organizations on this list;
      With you or your personal representative; and
      As allowed by law.
In addition to the people and organizations listed below in the Privacy and Confidentiality section of this
document, the following groups of people may also be able to see information about you and may use
the information to conduct the research:
      The medical staff that takes care of you and those who are part of this research study;
      Each research site for this study. This includes the research and medical staff at each site and
       USF;
      Any laboratories, pharmacies, or other individuals and organizations that use your health
       information as part of the approved plan for this study; [If not applicable, please delete this
       item.]
      The designated peer review committees such as [add all that apply: Protocol Review and
       Monitoring Committee; Data and Safety Monitoring Board; VA Research Services; etc.];
      Data Safety Monitoring Boards or others who monitor the data and safety of the study: [If not
       applicable, please delete this item.]
      Additionally, there may be other people and/or organizations who may be given access to your
       personal health information. This includes [List any other persons, classes of persons, and/or
       organizations. Do not list persons or entities who are likely to change over the course of the
       study, instead list them by title or category only. If not applicable, please delete this item.]
Who else can use and share this information?
Anyone listed above may use consultants in this research and for the purpose of this study, may share
your information with them. If you have questions about who they are, you should ask the study team.
Individuals who receive your health information for this research study may not be required by the
HIPAA Privacy Rule to protect it and may share your information with others without your permission.
They can only do so if permitted by the laws governing them. For example, the study sponsor may share
your information with others. If the sponsor or others share your information, your information may no
longer be protected under the HIPAA Privacy Rule.
How will my information be used?
By signing this form, you are giving your permission to use and/or share your health information as

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described in this document for any and all study/research related purposes. Your authorization to use
your health information will not expire unless you revoke it in writing.
As part of this research, USF may collect, use, and share the following information:
      Your whole research record [if the entire medical record is not used, then please modify as
       needed]
      All of your past, current or future medical and other health records held by USF, other health
       care providers or any other site affiliated with this study. This includes, but is not limited to,
       HIV/AIDs, mental health, substance abuse, and/or genetic information. [Modify to match what
       data will be collected and used in your study]
      [List any other needed information not included above. The descriptions should have enough
       detail that you (or any organization that must disclose information pursuant to this
       authorization) can understand what information may be used or disclosed.]
You can list any particular information that you do not want us to use or share in the space below. If
you list nothing here, we can use and share all of the information listed above for this research but for
nothing else.
For the Research Participant (you) to complete:
     I am asking USF and the researchers not to include, use, or share the following health information
     in this research (if blank, then no information will be excluded):




Your Rights:
You can refuse to sign this form. If you do not sign this form you will not be able to take part in this
research study and therefore not be able to receive the research related interventions. However, your
health care outside of this study and benefits will not change.


How Do I Withdraw Permission to Use My Information?
You can revoke this form at any time by sending a letter clearly stating that you wish to withdraw your
authorization to use of your health information in the research. If you revoke your permission:
      You will no longer be a participant in this research study;
      We will stop collecting new information about you;
      We will use the information collected prior to the revocation of your authorization. This
       information may already have been used or shared with other, or we may need it to
       complete and protect the validity of the research; and
       Staff may need to follow-up with you if there is a medical reason to do so.
To revoke this form, please write to:
       Principal Investigator [DO NOT insert a name here, merely the title]
       For IRB Study # [Insert IRB Study #]
       [Insert complete mailing address]
While we are conducting the research study, we cannot let you see or copy the research information we

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have about you. After the research is completed, you have a right to see the information about you, as
allowed by USF policies.

[This section must appear in each informed consent form.]

Privacy and Confidentiality
We will keep your study records private and confidential. Certain people may need to see your study
records. By law, anyone who looks at your records must keep them completely confidential. The only
people who will be allowed to see these records are:
          The research team, including the Principal Investigator, study coordinator, research nurses,
           and all other research staff. [Do not list the actual names of the Principal Investigator or
           staff as they may change over the course of the study]
          Certain government and university people who need to know more about the study. For
           example, individuals who provide oversight on this study may need to look at your records.
           This is done to make sure that we are doing the study in the right way. They also need to
           make sure that we are protecting your rights and your safety.
          Any agency of the federal, state, or local government that regulates this research. This
           includes the Food and Drug Administration (FDA), Florida Department of Health, and the
           Department of Health and Human Services (DHHS) and the Office for Human Research
           Protection (OHRP). [List any other federal, state, or local agencies/individuals authorized to
           access records)]
          The USF Institutional Review Board (IRB) and its related staff who have oversight
           responsibilities for this study, staff in the USF Office of Research and Innovation, USF
           Division of Research Integrity and Compliance, and other USF offices who oversee this
           research.
          The sponsors of this study and contract research organization [If not applicable, please delete
           this item.]
We may publish what we learn from this study. If we do, we will not include your name. We will not
publish anything that would let people know who you are.




Voluntary Participation / Withdrawal
You should only take part in this study if you want to volunteer. You should not feel that there is any
pressure to take part in the study. You are free to participate in this research or withdraw at any time.
There will be no penalty or loss of benefits you are entitled to receive if you stop taking part in this
study. [If participants are students or employees, include as applicable: “decision to participate or not
to participate will not affect your student status (course grade) or job status.”]




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New information about the study
During the course of this study, we may find more information that could be important to you. This
includes information that, once learned, might cause you to change your mind about being in the study.
We will notify you as soon as possible if such information becomes available.

Questions, concerns, or complaints
If you have any questions, concerns or complaints about this study, or experience an adverse event or
unanticipated problem, call [name of principal investigator] at [telephone #].
If you have questions about your rights as a participant in this study, general questions, or have
complaints, concerns or issues you want to discuss with someone outside the research, call the USF IRB
at (813) 974-5638. [Research conducted at USF Affiliates should insert Affiliate contact information
here.]
[If your study involves FDOH facilities and/or patients include the following:]
If you have questions about your rights as a person taking part in this research study you may contact the
Florida Department of Health (DOH) Institutional Review Board (IRB) at (866) 433-2775 (toll free in
Florida) or 850-245-4585.

What if you get sick or hurt while you are in the study?
If you need emergency care:
       Go to your nearest hospital or emergency room right away or call 911 for help. It is important
        that you tell the doctors at the hospital or emergency room that you are participating in a research
        study. If possible, take a copy of this informed consent form with you when you go. USF does
        not have an emergency room or provide emergency care.
       Call the study doctors as soon as you can. They will need to know that you are hurt or ill. Call
        [Name of Study Doctor at Telephone #] or [alternate telephone #].
If you do NOT need emergency care:
       Go to your regular doctor. It is important that you tell your regular doctor that you are
        participating in a research study. If possible, take a copy of this informed consent form with you
        when you go.
       The USF Medical Clinics may not be able to give the kind of help your child needs.


Will I be compensated for research related injuries?
If you believe you have been harmed because of something that is done during the study, you should call
[PI’s name] at [insert telephone number] immediately. The University of South Florida will not pay for
the cost of any care or treatment that might be necessary because you get hurt or sick while taking part
in this study. The cost of such care or treatment will be your responsibility. In addition, the University
of South Florida will not pay for any wages you may lose if harmed by this study. The University of
South Florida is considered a state agency and therefore cannot usually be sued. However, if it can be
shown that the researcher, or other USF employee, is negligent in doing his or her job in a way that
harms you during the study, you may be able to sue. The money that you might recover from the State
of Florida is limited in amount.
You can also call the USF Self Insurance Programs (SIP) at 1-813-974-8008 if you think:
    Your child was harmed because he/she took part in this study.

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      Someone from the study did something wrong that caused your child harm, or did not do
       something they should have done.
      Ask the SIP to look into what happened.

Affiliate Statement
[if applicable, insert your Institution-approved injury statement here.]

Sponsor Statement
[if applicable, insert the Sponsor Statement consistent with the industry contract here.]

What happens if you decide not to take part in this study?
You should only take part in this study if you want to volunteer. You should not feel that there is any
pressure to take part in the study to please the study doctor or the research staff. If you decide not to take
part in the study you will not be in trouble or lose any rights you normally have. You will still have the
same health care benefits and get your regular treatments from your regular doctor.

You can decide after signing this informed consent document that you no longer want to take part in this
study for any reason at any time. If you decide you want to stop taking part in the study, tell the study
staff as soon as you can.
     We will tell you how to stop safely. We will tell you if there are any dangers if you stop
         suddenly. [Specify if there are any consequences of a participant’s decision to withdraw from the
         research.]
     If you decide to stop, you can continue getting care from your regular doctor.
     [Describe the procedures for the orderly termination of participation by the participant.]
Even if you want you to stay in the study, there may be reasons we will need to withdraw you from the
study. You may be taken out of this study if we find out it is not safe for you to stay in the study or if
you are not coming for the study visits when scheduled. We will let you know the reason for
withdrawing you from this study.



                    Consent of Legally Authorized Representative (LAR)

 And Authorization for the Collection, Use and Disclosure of Health Information [if
                                    applicable]

It is up to you to decide whether you want the individual to take part in this study. If you want this
person to take part, please read the statements below and sign the form if the statements are true.

I give consent to have ________________________________________________ (name of participant)
take part in this study and authorize that his/her health information as outlined above. I have received a
copy of this form to take with me.
I understand that I am being asked to serve as the LAR and give permission for the individual outlined
above to participate in this research study. [If applicable My signature on this form also gives
authorization for the collection, use and sharing of private health information.] My decision is based on
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what I believe this individual would choose for him/herself and what I believe is now best for him/her,
based on the information I have been provided.




Signature of Legally Authorized Representative                                      Date


Printed Name Legally Authorized Representative




                   Determination of the Person’s Ability to Give Consent
A.   I am the study participants __________________________ [doctor, counselor, therapist, etc.]. I
     have examined this individual by [insert method outlined in protocol] and have found that he/she
     has limited/diminished capacity and therefore is unable to give informed consent to take part in the
     research study and the legally authorized representative signing above is an appropriate LAR.

     ______________________________________________________________
     Signature of Person Attesting to Limited/Diminished Autonomy of Participant             Date

     ______________________________________________________________
     Printed Name of Person Attesting to Limited/Diminished Autonomy of Participant

                                             -OR-

B.   I am a physician licensed in the State of Florida. I agree that this person has limited/diminished
     capacity and therefore is unable to give consent.



     _____________________________________________________
     Signature of Physician                                                         Date

     _____________________________________________________
     Printed Name of Physician

[This section is to be included when the participant is a pregnant woman. Delete this section if research
does not involve pregnant women].
Paternal Consent
If you were pregnant or become pregnant, the particular treatment or procedure might involve risks to
the embryo or fetus, which were currently unforeseeable.



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Signature of father of unborn child                                         Date

The signature of the father was not obtained because:
                              available
         Other reasons:


     Statement of Person Obtaining Informed Consent / Research Authorization
I have carefully explained to the LAR of the person taking part in the study what he or she can expect
from participation. I hereby certify that when this person signs this form, to the best of my knowledge,
he/ she understands:
     What the study is about;
     What procedures/interventions/investigational drugs or devices will be used;
     What the potential benefits might be; and
     What the known risks might be.

I can confirm that the LAR speaks the language that was used to explain this research and is receiving
an informed consent form in the appropriate language. Additionally, this LAR reads well enough to
understand this document or, if not, this person is able to hear and understand when the form is read to
him or her. This LAR is not under any type of anesthesia or analgesic that may cloud their judgment or
make it hard to understand what is being explained and, therefore, can be considered competent to give
informed consent.

_______________________________________________________________                     _______________
Signature of Person Obtaining Informed Consent / Research Authorization             Date

_______________________________________________________________
Printed Name of Person Obtaining Informed Consent / Research Authorization




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                          [Delete this section if it does not pertain to your study]

                         Addendum to the Consent and Authorization
                       to obtain and store [blood and/or tissue] samples.
We are asking you to allow us to obtain and store samples of your [blood and/or tissue] for use in future
research. These samples may be used for research on your disease or condition and others to assist in
the development of new treatments for disease. We will take some of your [blood/ tissue and location on
the body from which they will be removed]. This [will/will not] be in addition to the [blood/tissue]
already being obtained for treatment or research purposes. [If extra blood or tissue is being taken,
explain how much extra will be taken and how this will impact the procedures for obtaining the samples.
Ex: We will take an extra teaspoon of blood during a scheduled blood draw. Or we will take an extra
tissue during the time of biopsy. This will not increase the time it takes to complete the biopsy Be sure to
include any additional risks the collection of blood or tissue will have on the research subject.]

When you sign below, you are agreeing to let us store and use your [blood and/or tissue] for future
research studies. We may use these samples to help us:
        Learn more about your disease.
        Learn how [the experimental drug, device, procedure, or biologic] works.
        Find new ways to help people with your disease or condition or other conditions.
        Someday learn how to cure your disease or condition.

Your sample will be store [where] for [how long in years. It is also appropriate to say that it will be
stored until it is used up] and will be destroyed after this period of time. Your sample [will/will not] be
stored with identifying information. We will not tell other people your name or other information that
identifies you unless it is required by law.

[If the sample is not linked, add the following language:]
No one will know that the [blood/ tissue] sample came from you. Since we did not link your name or
other identifying information to the [blood/ tissue] sample, once you agree to allow us to use this
sample, you cannot change your mind. We will not be able to find your sample to remove it from all the
others we collect. Once the sample is provided, it is forever separated or “unlinked” from your
identifying information to protect your privacy. When this occurs, the researchers will not be able to
provide you with information discovered from your sample.
Even though your name will not be connected with the tissue or blood sample, other information about
you might still be connected. Examples of this information may be your race, ethnicity, or parts of your
medical history.
[If the genetic sample is linked, add the following language]
Since your sample is linked to your identifying information such as name or medical record number,
should you choose to withdraw your consent to use the sample at a later date, please contact the study
doctor. The study doctor will remove your sample from the research and immediately destroy it so that it
can no longer be used. Please understand that part your sample may have been used prior to the
withdrawal of your consent.


[Include as applicable]

IRB Number:                                                               Informed Consent Rev #
IC Proxy RA Template – 2010-09-05                                         IRB Consent Rev. Date:
                                                                                                 Page 13 of 14
In addition to using your sample for this study and future research, we would like to share it with other
researchers. We will code your sample so that the researcher who uses it for other research purposes
does not know your identity. We will not release the code that links your sample to your personal
identifying information for any reason.


You can decide if you want us to store and use your samples in the future. You do not have to agree to
this in order for you to take part in the study that has been explained to you. By singing this form, you
give consent to provide [specify exactly what you are asking the person to donate] for future research
purposes.


________________________________________________                            __________________
Signature of Legally Authorized Representative                              Date

________________________________________________
Printed Name of Legally Authorized Representative



 _______________________________________________________________                    _______________
Signature of Person Obtaining Informed Consent                                      Date

 _______________________________________________________________
Printed Name of Person Obtaining Informed Consent




IRB Number:                                                             Informed Consent Rev #
IC Proxy RA Template – 2010-09-05                                       IRB Consent Rev. Date:
                                                                                               Page 14 of 14

				
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posted:10/25/2011
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