Vir-Sp-000-F3 - Laboratory Test Request For Service Sample And Consent Form Page 2
ADVERTISEMENT
1
2Collection, storage and transportation of patient specimen
1. Blood specimen for Dengue/JE should be collected 2 times during 5-7 days, 3-4 ml or collected on admission and discharged date. Keep specimen at 2-
8 ํ C (on ice) and send to the lab, specimen could be leaved at ambient temperature 24 hours.
2. Collect throat/nasal swab and store in Viral Transport Media (VTM) which provided by Virology Dept, two swabs per tube. Keep specimen at 2-8 ํ C and
send to the lab within 48 hours. Do not keep specimen in -20
O
C freezer.
3. Labeled specimen information; subject name, collecting date and type of specimen.
Consent Form for Sample Donation
(Version: 9 JANUARY 2008)
Title: United States Army Medical Component-Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS), Department of Virology
Specimen Repository
Purpose of Document: This document gives you information to decide whether you want to donate your sample for future research by the
Department of Virology.
Statement: Department of Virology, AFRIMS provides free diagnostic work on samples received from health agencies. Possible sample types
could include blood or blood components, cerebral spinal fluid, respiratory specimens, and body fluid or tissue. Once the results have been
transmitted, your samples will be destroyed unless you give us permission to store samples at the Department of Virology. These archived
samples may then be used for evaluating new diagnostic tests or infectious disease research. With your permission, additional testing may be
considered but only after the review and approval of Ethical Review Committees.
Confidentiality: The personal data will be removed from your sample and the Department of Virology data. When the results of the research are
published or discussed, no information will be included that would reveal your identity.
Agreement: Your sample will be stored at AFRIMS and has been coded to remove any personal information. Donation of sample is voluntary and
you will not be paid for your donation. You will not receive the results of any future testing. Your decision to donate your sample for additional
research WILL NOT affects your medical benefit or the free testing.
I
do /
do not (check one) wish to donate my sample for future research with approval from appropriate ethical review committees.
Subjects/Guardian/Parent Signature: _________________________________________
Printed Name: _____________________Date:________________ (DD/MM/YY)
Witness Signature: _____________
________________________
Printed Name:
_______Date:_______________ ( DD/MM/YY)
VIR-SP-000-F3
Page 2 of 2
27 May 08
FOR OFFICIAL USE ONLY
ADVERTISEMENT
0 votes
Related Articles
Related forms
Consent And Request For Law Enforcement And Agency Records Form - Douglas County Social Services Department
Legal
Form W-9 (substitute) - Request For Taxpayer Identification And Certification - Oregon Department Of Administrative Services
Financial
Related Categories
Parent category: Business