Note to User

Note to user:

This model form can be used for obtaining written consent for registration with a brain donation program. Form can be modified accordingly to obtain patient’s consent for clinical autopsy.

Please note that ethics committee’s explicit approval for the use of this consent form may be required by the local legislation or regulations. Please also consider the checklist before distributing any donor information! If in doubt seek local legal advice.

Informed consent to brain donation (A)

Name of the donor MaleFemale

Surname

Date of birth

Address

Postal code,

City

Phone number

I have been provided and understood information on brain donation to the <BRAIN BANK> and hereby give consent to autopsy, as well as to the removal of the bodily tissue checked below and storage for an indefinite period of time at the <BRAIN BANK> for scientific research purposes.

Brain

Spinal cord

Note to user:

Explicit consent for removal of any other tissue should be explicitly stated.

After my death the<BRAIN BANK> is allowed to retrieve the necessary information from my medical files from my treating physicians. The<BRAIN BANK>is allowed to process my medical information and to store it for an indefinite period of time for scientific research purposes.

The<BRAIN BANK> is allowed to supply my bodily tissue and a summary of my medical information to approved optionally approved by Ethics Committee or IRB> research projects on brain diseases as well as research projects on the normal physiological functioning of the brain.

Note to user:

Explicit consent for genotyping studies may be required. If in doubt seek local legal advice.

I understand that I can withdraw this consent at any time, without stating a reason.

I DO DO NOT object to the neuropathological report being discussed with my relatives.

To be filled in by the donor:

Place

Date

Signature: ______

Additional information for the registration as brain donor:

This information will be processed in strict confidentiality, solely for the purpose of accurate performance of the autopsy.

Note to user:

Any additional information which may be required about the donor can be included here. Purposes for which information is collected should be clearly stated.

Have you (ever) been diagnosed with any of the following disorders?

NoYes, with ** Please check the appropriate box(es).

Parkinson's disease (PD)

Progressive supranuclear palsy (PSP)

Multi-system atrophy (MSA)

Alzheimer's disease (AD)

Frontotemporal dementia (FTD)

Amyotrophic lateral sclerosis (ALS)

Multiple sclerosis (MS)

Epilepsy

Narcolepsy

Diabetes mellitus

Thyroid disorder

Migraine or other headache disorder

Depression

Bipolar disorder

Personality disorder

Schizophrenia

Other psychiatric disorder, namely

Retinitis pigmentosa

Macula degeneration

Other, namely

If yes, who is your treating physician with regard to this disorder?

Name specialist MaleFemale

Hospital + division

Address

Postal code

City

Co-signature

This part should be filled in by someone who is close to you, such as your spouse, registered partner or other life companion, or in absence of such person, by an adult child or other adult family member, or in absence of such person, the signature of an adult heir or confidant will suffice.

Note to user:

Co-signature may or may not be require by the local legislation/regulations.

I hereby declare that I have taken note of the decision of the person concerned, to become brain donor at the <BRAIN BANK>. I am aware of the consequences of the registration and the procedures of the <BRAIN BANK>. I fully understand that, unless withdrawn by the donor, the consent will remain valid regardless time passing since signing.

NameMaleFemale

Relation to brain donor

Date of birth

Address

Postal code, city

Phone number

Note to user:

Explicit consent to receive results on genotyping may be required. If in doubt seek local legal advice.