Adult Informed Consent To Participate In A Research Study (Page 5 of 7) in pdf

Adult Informed Consent To Participate In A Research Study Page 5

The saliva specimens obtained for the purposes of this study will be collected by

UCLA. Once you provide the specimens you will not have access to them. The

specimens will be used for research and such use may result in inventions or

discoveries that could become the basis for new products or diagnostic or

therapeutic agents. In some instances, these inventions and discoveries may be

of potential commercial value and may be patented and licensed by the

University. You will not receive any money or other benefits derived from any

commercial or other products that may be developed from use of the specimens.

WHAT ARE YOUR RIGHTS AS A PARTICIPANT, AND WHAT WILL

HAPPEN IF YOU DECIDE NOT TO PARTICIPATE?

Your participation in this study is VOLUNTARY. Your decision whether or not to

take part will not affect your current or future care or your relationship with

UCLA or your right to health care or other services to which you are otherwise

entitled.. You are not waiving any legal claims or rights. If you do decide to

take part in this study, you are free to change your mind and withdraw your

consent and discontinue participation at any time without prejudice to your

future care at UCLA.

NEW FINDINGS

During the course of this study, you will be informed of any significant new

findings (either good or bad), such as changes in the risks or benefits resulting

from participation in the research or new alternatives to participation, that might

cause you to change your mind about continuing in the study. If new

information is provided to you, your consent to continue participating in this

study will be re-obtained.

WHOM DO YOU CALL IF YOU HAVE QUESTIONS OR PROBLEMS?

You may contact Dr. Marlena S. Fejzo at 310-383-3581 with any questions or

concerns about your participation in this study. If you feel you have been hurt

by taking part in this study, please contact Dr. Marlena S. Fejzo at 310-383-

3581. If you have any questions about your rights as a study subject, please

contact the University of California, Los Angeles, Office of Protection of Research

Subjects, 11000 Kinross Avenue, Box 951694, Los Angeles, CA, 90095-1694

(Telephone number: 310- 825-8714). You will get a copy of this consent form.

Protocol ID:IRB#11-001681

UCLA IRB Approved Approval Date: 9/15/2014 Through: 9/14/2015 Committee: Medical IRB 1

Adult Informed Consent To Participate In A Research Study Page 5