Research Consent Form

Dana-Farber/ HarvardCancerCenter

BIDMC/BWH/CH/DFCI/MGH/DFPCC Network AffiliatesOHRS 07.17.15

WITHDRAWAL OF CONSENT TO CONTINUE IN RESEARCH

A. Introduction

You are currently taking part in a research study. Study participation is voluntary and you may decide to stop taking part now or at any time. If you decide to stop participating in this research study, we encourage you to talk to the research doctor and your regular doctor first.

Information about the study you are participating in, including the study number, study title and name of the doctor who is overseeing the study (Principal Investigator) is listed below:

Study
Number / Study Title / Principal Investigator Name
  1. Documentation of withdrawal of consent to continue in research

Using this form, we are asking you to document your decision to withdraw from this research study or to specify any components of the study you agree to continue to participate in.

withdrawal of consent to continue on Study:

Please initialyour choice below:

_____ I withdraw my consent to continue the study treatment. I agree to continue as a study participant for follow-up visits and allow tests to be completed that will continue to be used for research purposes.

_____ I withdraw my consent to continue the study treatment and I will not allow more tests to be completed for research purposes.However (select as applicable):

_____ I agree to continue as a study participant by allowing information collected from my medical records to be used for research purposes.

_____I agree to continue as a study participant by allowing the study team to contact my primary care physician for research-related information.

_____ I agree to continue as a study participant by allowing the study team to contact my family/caregiver for researchrelated information.

_____ I withdraw my consent to participate in any component of this research study. I do not want any further medical information to be used for this research. Information that has already been obtained will remain as part of the research record, but no additional information will be added to the research record.

______I withdraw my consent to continue to participate in research activities such asbanking, questionnaires andinterviews,Information that has already been obtained will remain as part of the research, but no additional information can be added to the research record.

Not Applicable – No study intervention was involved.

Please note: If you are participating in a Food and Drug Administration (FDA) regulated research study and you decide to stop participating in the study, the FDA requires that any information collected up to the point of your withdrawal cannot be removed from the study.

biological specimen withdrawal of consent:

Please initial your choice below:

_____ Tissue and blood samples collected as part of the study may continue to be stored for future research purposes.

_____ Tissue and blood samples collected as part of the study may not be stored for future research purposes and I request that they be destroyed at the facility where they are presently being stored. I understand that samples that have already been used cannot be withdrawn.

Not Applicable – No specimens have been collected.

  1. SIGNATURE

Participant Signature Date

Participant Printed Name______

Legally Authorized RepresentativeDate ______

Legally Authorized Representative Not Applicable

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