Delete the section that does NOT apply to your research.

APPENDIX B
NOTE: This template is required when obtaining specimens for future research that will be identified (linked back to the original donor).
See Appendix C if the specimens will be de-identified.

USE OF IDENTIFIED SPECIMENS FOR FUTURE RESEARCH:

In addition to the research you are consenting to under this research study, Dr. ________________ or other researchers at this or other institutions may wish to study the samples in future research, including genetic analysis. These samples, taken from your body, would be able to be linked back to you. Information about you may be shared with other researchers who will keep the information confidential. However, it is possible that information about you may become known to people other than the researchers.

At this time, the researcher does not know what the future studies will be. Your specimens may also be submitted to a tissue/cell/DNA bank. The specimens may be kept for a long time and may exceed 50 years. You have the right to withdraw consent to use of the tissue for future use at any time by contacting the supervisor of the study named on the first page of the consent or the CCI office at 718-430-2253. Unused specimens will be destroyed.

In some research using human blood or tissue, the specimens and their parts may enable researchers to develop medical tests or treatments that have commercial value. You will not receive any money that may result from any such commercial tests or treatments.

Your specimens may be used for future research, even though the purpose of the future research is not known at this time.

PARTICIPANT:
PLEASE INDICATE YOUR CHOICE BY INITIALING ONE (1) OF THE FOLLOWING OPTIONS

___ I consent to have my specimens used for future research studies.

___ I consent to have my specimens used for future research studies only for the study of _____________________________________.

___ I do NOT consent to have my specimens used for future research studies. The specimens will be destroyed at the end of the study.

PARTICIPANT:
FOR FUTURE CONTACT, PLEASE INITIAL YOUR CHOICES BELOW

I consent to be contacted in the future to learn about:

_____ New research protocols that I may wish to join.

_____ General information about research findings.

_____ Information about the test on my sample that may benefit me or my family members in relation to choices regarding preventive or clinical care.

_____ I DO NOT AGREE TO BE CONTACTED IN THE FUTURE, EVEN IF THE RESULTS MAY BE IMPORTANT TO MY HEALTH OR MY FAMILY'S HEALTH.

APPENDIX C
NOTE: This template is required when obtaining specimens for future research that will be de-identified (not linked back to the original donor).
When uncertain, use the Appendix B template.

USE OF DE-IDENTIFIED SPECIMENS FOR FUTURE RESEARCH:

In addition to the research you are consenting to under this research study, Dr. ________________ or other researchers at this or other institutions may wish to study the samples in future research, including genetic analysis. These samples, taken from your body, would NOT be linked back to you. No one will know your name or protected health information.

At this time, the researcher does not know what the future studies will be. Your specimens may also be submitted to a tissue/cell/DNA bank. The specimens may be kept for a long time and may exceed 50 years.

In some research using human blood or tissue, the specimens and their parts may enable researchers to develop medical tests or treatments that have commercial value. You will not receive any money that may result from any such commercial tests or treatments.

Your specimens may be used for future research, even though the purpose of the future research is not known at this time.

PARTICIPANT:
PLEASE INDICATE YOUR CHOICE BY INITIALING ONE (1) OF THE FOLLOWING OPTIONS

___ I consent to have my specimens used for future research studies.

___ I consent to have my specimens used for future research studies only for the study of _____________________________________.

___ I do NOT consent to have my specimens used for future research studies. (The specimens will be destroyed at the end of the study.)

Dated: 6.01
Revised 1.02, 1.07