CONSENT FOR CANCER RESEARCH

Project Title:

Principal Investigator:

Sponsor:

Cancer research studies are coordinated by physicians and scientists from Cleveland Clinic, UniversityHospitals and Case Western Reserve University (CWRU) through the NIH National Cancer Institute (NCI) designatedCaseComprehensiveCancerCenter (CaseCCC). The goal of this collaboration is to enhance cancer treatment and research in Northeast Ohio. This study is being offered at insert institution(s) Cleveland Clinic (CC) and/or UniversityHospitals (UH)

The opening paragraph is mandatory

1. Introduction

  1. Purpose

3. Study Procedures

  1. Risks

Genetic Studies(if applicable)

5. Benefits

6. Alternatives to Participation

7. Costs and Compensation

8. Research-Related Injury

9. Privacy and Confidentiality

HIPAA (required)

B. Authorization to Use or Disclose (Release) Health Information that Identifies Youfor a Research Study

If you volunteer to participate in this research, your protected health information (PHI) that identifies you will be used or disclosed to [insert name(s) of Principal Investigator(s)]and the research staff atCleveland Clinic and/or University Hospitals[select appropriate institution]for the purposes of this research and to Case Western Reserve University for administration.

The PHI that we may use or disclose (release) for this research may include your name, address, phone number, date of birth, Social Security number, information from your medical record, lab tests, or certain information relating to your health or condition..

Some of the tests and procedures done solely for this research study may also be placed in your medical record so other doctors know you are in this study. Upon completion of the study, you may have access to the research information that is contained in your medical record.

In addition to the investigators and research staff listed above, your PHI may be looked at by other groups involved with the study such as the Cleveland Clinic Institutional Review Board, University Hospitals Institutional Review board (select only applicable Review Board)and the Case Comprehensive Cancer Center Protocol Review and Monitoring Committee. Your PHI may also be used by and/or disclosed (released) to:

Include the Name or class of persons involved in the research such as research collaborators, sponsors, and others who will have access to data that includes PHI. Choose all that are applicable and insert (Examples may include, but are not limited to the following):

  • Study sponsors and their agents (please include name of sponsor);
  • The Food and Drug Administration;
  • The Department of Health and Human Services;
  • The National Cancer Institute (NCI);
  • Other Institutional Review Boards;
  • Data Safety and Monitoring Boards;
  • Insert other parties as appropriate

Once your personal health information is released it may be re-disclosed and no longer protected by privacy laws.

Your research information may be used and disclosed indefinitely, but you may stop these uses and disclosures at any time by writing to [insert name of PI and address and phone number]. Your participation in the research will stop, but any information previously recorded about you cannot be removed from the records and will continue to be used as part of this research. Also, information already disclosed outside the Cleveland Clinic cannot be retrieved. This will not affect your rights to treatment or benefits outside the research study.

The Cleveland Clinic and/or UniversityHospitals[insert appropriate site(s)] will not use your information collected in this study for another research purpose without your written permission; unless the Cleveland Clinic Institutional Review Board (IRB) and/or University Hospitals Institutional Review Board [insert appropriate site(s)] assures your privacy and confidentiality is protected. The IRB is a committee whose job it is to protect the safety and welfare of research subjects.

By signing this informed consent form, you are authorizing such access to your research and medical record information. If you choose not to sign this consent form, you will not be able to participate in this research study. This Authorization does not have an expiration date.

10. Voluntary Participation

Student/Employee Rights

Termination of Participation

11. Questions About the Research

Emergency and After-hours Contact Information

Where Can I Get More Information?

You may call the National Cancer Institute’s Cancer Information Services at:

1-800-4-CANCER (1-800-422-6237)

You may also visit the NCI website at

  • For NCI’s clinical trials information, go to:
  • For NCI’s general information about cancer, go to

You will get a copy of this form. If you want more information about this study, ask your study doctor.

US National Institutes of Health (NIH) Clinical Trial Database

A description of this clinical trial will be available on as required by U.S. Law. This Web site will not include information that can identify you. At most, the Web site will include a summary of the results. You can search this Web site at any time.

12. Signature

Signing below indicates that you have been informed about the research study in which you voluntarily agree to participate; that you have asked any questions about the study that you may have; and that the information given to you has permitted you to make a fully informed and free decision about your participation in the study. By signing this consent form, you do not waive any legal rights, and the investigator(s) or sponsor(s) are not relieved of any liability they may have. A copy of this consent form will be provided to you.

[Add the appropriate signature block from the choices below. Do not start the signature block on a new page unless this page is full.]

[Signature format for studies enrolling only adults]

Signature of ParticipantDate Printed Name of Participant

[USE THIS WHEN A WITNESS IS USED IN THE CONSENTING PROCESS (Common examples include: Inclusion of illiterate individuals, blind individuals or individuals who cannot physically sign but are able to provide informed consent.)]

Signature of Witness Date Printed Name of Witness

I have discussed the information contained in this document with the participant and it is my opinion that the participant understands the risks, benefits, alternatives and procedures involved with this research study.

Signature of Person Obtaining ConsentDate

Printed Name of Person Obtaining Consent

[USE THIS FOR STUDIES ENROLLING DECISIONALLY IMPAIRED ADULTS]

x
Signature of Participant Date
x
Printed Name of Participant
If participant does not have the capacity to consent and protocol is approved for inclusion
x
Signature of Legally Authorized Representative (LAR) or Next of Kin Date
x
Printed name of Legally Authorized Representative (LAR) or Next of Kin
If Next of Kin, please mark ONE relationship from list below (in decending order of priority):
Spouse / Adult Child / Custodial Parent / Adult Sibling / Adult relative (related by blood or adoption)

[Signature format for studies enrolling both adults and children or legally incompetent adults]

Printed Name of ParticipantDate

Signature of Participant or Child’s Signature if this form is used to obtain assent

(for minors ages ≥14 years of age)

If Participant is a minor or legally incompetent adult:

Printed Name of Parent or Legal GuardianDate

Signature of Parent or Legal Guardian Relationship to Participant Date

______

Second Signature of Parent or Legal Guardian Relationship to Participant Date

I have discussed the information contained in this document with the participant and it is my opinion that the participant understands the risks, benefits, alternatives and procedures involved with this research study.

Signature of Person Obtaining ConsentDate

Printed Name of Person Obtaining Consent

[Signature format for studies enrolling only children (45 CFR 46.404 and 46.405)]

Printed Name of ParticipantDate

Child’s Signature if this form is used to obtain assent

(for minors ages ≥14 years of age)

Printed Name of Parent or Legal GuardianDate

Signature of Parent or Legal Guardian Relationship to ChildDate

Second Signature of Parent or Legal Guardian Relationship to Participant Date

I have discussed the information contained in this document with the participant and it is my opinion that the participant understands the risks, benefits, alternatives and procedures involved with this research study.

Signature of Person Obtaining ConsentDate

Printed Name of Person Obtaining Consent

[Signature format for studies of children, classified as 45 CFR 46.406 requiring both parent’s signatures]

Printed Name of ParticipantDate

Child’s Signature if this form is used to obtain assent (for minors ages ≥14 years of age)

Printed Name of Parent or Legal GuardianDate

Signature of Parent or Legal Guardian Relationship to ChildDate

I have discussed the information contained in this document with the participant and it is my opinion that the participant understands the risks, benefits, alternatives and procedures involved with this research study.

Signature of Person Obtaining ConsentDate

Printed Name of Person Obtaining Consent

Second Parent Signature Relationship to Child Date

If only one parent can sign this consent, indicate the reason that applies to the other parent:

□ Deceased

□ Unknown

□ Legally incompetent

□ No legal responsibility for the care and custody of the child

□ Not reasonably available—indicate why:

(Acceptable reasons for this category must not be based on convenience)

Insert Protocol Number/Version Date

Insert Consent Descriptor (i.e., A/B/C, Main Study, Optional Biopsy, etc.) & Version Date

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Cancer Consent Template [Version 12-10-14]