Adult Informed Consent To Participate In A Research Study (Page 6 of 7) in pdf

Adult Informed Consent To Participate In A Research Study Page 6

AGREEMENT:

I have read (or someone has read to me) the information provided above. I

have been given a chance to ask questions. All my questions were answered to

my satisfaction. I have decided to sign this form in order to take part in this

study. This form with your signature, should be faxed or mailed to the Principal

Investigator, Dr. Fejzo, who will then sign the form and mail a copy back to you.

BY SIGNING THIS FORM, I WILLINGLY AGREE TO PARTICIPATE IN THE

RESEARCH IT DESCRIBES.

Name of Adult Subject

Signature

Date Signed

SIGNATURE OF INVESTIGATOR:

I have explained the research to the subject and answered all of her questions.

I believe that she understands the information described in this document and

freely consents to participate.

Name of investigator

Signature

Date Signed

Information About Fluid Samples Collected as Part of This Research:

Please mark how your saliva cell samples may be used by initialing “Yes” or “No.”

No matter what you decide to do, it will not affect your participation in this

study.

a) My saliva cell samples may be kept for use in future research on HG.

Yes ______ No _______ Initials ______

b) Someone from UCLA may contact me in the future to take part in more

research.

Yes ______ No _______ Initials ______

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 6