Download Optional Consent Sections (DNA/Genetics/Childbearing Potential)

The following are optional.
Please insert applicable sections only into your consent form:

Genetic Studies (if applicable):
In order to interpret the results of genetic research, we need to have correct information about
parents. Sometimes the research shows new information about birth parents. This could
happen in the case of an adoption or a mistake in the identity of a mother or father. This
information will not be given to anyone, including yourself or family members.

Future use of tissue/DNA samples (if applicable):
In order to preserve a valuable resource, your [tissue/DNA] samples may be stored at the end
of this research project. It is possible that these samples may be used in a future research
project. This project will be related to [childhood cancer, asthma, etc.] as determined by a
research ethics committee. Any future research would have to be approved by a
Research Ethics Board (REB).
Please tick one of the following options:
I agree that my (tissue/DNA) sample can be used for approved (limit to what is being
studied, i.e. cancer, arthritis, etc.) research project without contacting me again, but
only if my name* cannot be linked, in any way, to the sample.
Under no circumstances may my sample be used for future research. My sample must
be destroyed at the end of this present project.
I agree that I may be contacted in future to be invited to provide consent for the use of
my [tissue/DNA] in any new approved research project.
*Includes name, MCP number or any other identifying information.
The (tissue/DNA) sample from this study will be stored in _______________________
(city/province) for (approximately ____ years/for an indefinite period of time).
[Explain the process for withdrawing or destroying any sample if the sample is stored
with any identifier which could link the sample back to the donor.]

Exclusion of women who are pregnant, intent to become pregnant or to breastfeed.
We do not have enough information about this drug to know whether it may affect the
fetus or a child who is being breastfed.
If you are pregnant or planning to become pregnant in the next [length of study]
months/years, you must not take part in this study. You must not breast feed while
you are in this study.
You will have a pregnancy test at the beginning of the study [and at regular times
throughout the study].
If you are not pregnant but are able to become pregnant, you must use a reliable form of
birth control throughout the study.
[If you do become pregnant during the study {or within x days of stopping the drug} you
must immediately inform the study doctor].