PERIPHERAL VENOUS BLOOD SAMPLING CONSENT FORM
Patients (ADULTS)
EXAMPLE
I, the undersigned
....................................................................................................................................................,
born at
......................................................................................................................,
on ........................................,
sex ............................ and resident in
......................................................................................................................,
Street/Square
...........................................................................................................................................................,
DECLARE
- that I have read the written information notice received and that
I have understood both the information contained therein
and the supplementary information provided orally by the
staff of the genetics practice;
- that I have read the information notice and signed the consent to
the processing of personal, special and genetic data;
INFORMED THAT:
- the information that can be obtained from the genetic analysis of
my RNA/DNA has value for the determination
of gene expression and sequence for research purposes;
- I may at any time order the destruction of the blood sample and
RNA/DNA extracted from it,
delegate another individual to order the destruction of the
sample and RNA/DNA after my death,
refuse permission to use the sample and RNA/DNA;
- I will still be asked for consent for any further use of the blood
sample or RNA/DNA extracted from the blood that is not part of this
study;
- I may request information on the results obtained from the overall
genetic analysis of the study, subject to specialist consultation
at licensed Medical Genetics Clinics;
- the sample provided by me and the RNA/DNA extracted from it will
be stored at ............................;
- the information of a personal nature contained in this form and
that deriving from the data obtained from the analysis of my RNA/DNA
will be
collected and stored in accordance with the regulations set
out in the information notice on the processing of personal, special
and genetic data;
I HEREBY GIVE MY CONSENT AND AUTHORISE, FOR RESEARCH PURPOSES, THE
MANAGERS OF THE STUDY,
AND UNDER THEIR RESPONSIBILITY, THE RESEARCHERS WITH RESPONSIBILITY
TO IMPLEMENT THE PROJECT
(please mark with an X the box of interest and sign in the spaces
below):
▢ at peripheral blood sampling (1-3 mL);
Place
......................................, Date
.........................., Signature
...............................................................
▢ to keep the biological sample obtained as above for a maximum of
20 years;
Place
......................................, Date
.........................., Signature
...............................................................
▢ to extract and store the relevant RNA/DNA for a maximum time of 20
years;
Place
......................................, Date
.........................., Signature
...............................................................
▢ to perform RNA/DNA analysis experiments (exome, transcriptome and
methylome analysis) and plasma analysis
in order to obtain data in the framework of
the study on the
...............................................................
Place
......................................, Date
.........................., Signature
...............................................................
▢ to the processing necessary for the carrying out of the genetic
study described in the points n. ... of the "information sheet"
describing the study -
of my personal, health and genetic data,
which will be carried out for the purposes, in the forms and in the
ways
specifically described in the points n. ...
of the above information sheet;
Place
......................................, Date
.........................., Signature
...............................................................
▢ that the results of the research, including any unexpected news
concerning me, be communicated to me, exclusively in the forms and
ways
provided for in the point n. ... of the
information notice (counselling at authorised Medical Genetics
Clinics),
if in the opinion of the study personnel they
represent a concrete and direct benefit for me in terms of therapy,
prevention
or awareness of reproductive choices;
Place
......................................, Date
.........................., Signature
...............................................................
▢ to contact me in the future for any further investigations;
Place
......................................, Date
.........................., Signature
...............................................................
in accordance with the regulations set out
in the information notice on the processing of personal, special and
genetic data
I ALSO DECLARE THAT I AM AWARE THAT
- the Research Managers are also responsible for the processing of
my personal data;
- the data are stored on electronic files;
- access to the data is protected by a password known only to the
Research Managers and, under their responsibility,
to the Researchers with responsibility for implementing the
project.
I FURTHER DECLARE that I have been informed by Dr.
............................................................. in a
thorough and detailed manner
of the aims and methodologies involved in the study project and that
I have received exhaustive answers to all the clarifications I
needed.
Aware that, should I deem it appropriate, I may, at any time,
withdraw my consent to the analysis of my sample and thus be
excluded from the study,
I undertake to promptly communicate any change of opinion.
Place ......................................, Date
..........................,
In faith, ..........................................................
The doctor collecting the consent
...........................................................