Samples Unlinked to Participant

As part of this study, we would like to store ____ (type of specimen, blood, urine, tissue, etc.) specimens collected from you for future research on _____ (condition). This future research may be conducted by ____ (PI’s name) or by other researchers who obtain IRB approval for their research. This research may/ will not involve genetic studies. The specimens will be de-identified/anonymized. This will protect your confidentiality and anonymity; it will also have other consequences:

  1. It will be impossible to withdraw these samples from any future research project. Your sample cannot be destroyed if it has been de-identified and can no longer be traced back to you.
  2. Results of any future research will not be given to you or your doctor.
  3. Even though your name and other personal identifiers will not be connected to the sample, other information about you might still be connected. For instance, information about your race, ethnicity, sex, your medical history, and so forth might be available to investigators studying your specimen. Such information might be important for research or public health. It is possible that this information (including genetic information) might come to be associated with your racial or ethnic group.
  4. The specimens obtained from you in this research may help in the development of a future commercial product. There are no plans to provide financial compensation to you should this occur.

If storage of specimens is an optional part of the study, include the following, as well as initial lines to document participants’ choice: You do not have to agree to allow your blood and urine specimens to be stored in order to be part of this study.

Initial your choice below:

___ Yes, I agree to allow my samples to be kept and used for future research.

___ No, I do not agree to allow my samples to be kept and used for future research.