Download FHCRC model consent

0000 [CENTER CANCER CONSORTIUM PROTOCOL NUMBER]
Fred Hutchinson Cancer Research Center
University of Washington
Consent to take part in an Investigational Treatment Protocol:
Treatment Use of [INVESTIGATIONAL PRODUCT] for a
Single Patient with [DISEASE]
Principal Investigator: [FIRSTNAME, LASTNAME, MD, PhD]
[TITLE, INSTITUTION]
Telephone: [206-XXX-XXXX]
Emergency number (24 hours): [000-000-0000]
[INSTRUCTIONS FOR EMERGENCY NUMBER, IF NEEDED – E.G., PAGING
OPERATOR]
FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: If this consent might be signed by a
legally authorized representative, parent or guardian on behalf of the participant, add the
following statement. Otherwise delete.
If you are serving as a legally authorized representative, a guardian, or are providing
parental permission for a child in this treatment plan, the terms “participant”, "you",
and "your" refer to the person for whom you are providing consent or parental
permission.
We invite you to join this investigational treatment protocol.
Your doctors are inviting you to participate in an investigational treatment protocol (a
specific plan for treatment). The purpose of this protocol is because you have [NAME
OF DISEASE] that has not responded to standard therapy. An investigational
treatment plan is a way to offer one patient a drug that would not be available
otherwise. This is also known as “compassionate use.” You would be the only person
to take part in this protocol.
If you agree to join the protocol, you [STATE THE PROCEDURES INVOLVED AS
BRIEFLY AS POSSIBLE].
We do not know if [NAME THE INVESTIGATIONAL PRODUCT] would help
[PREVENT OR TREAT] [NAME OF DISEASE]. [NAME OF
INVESTIGATIONAL PRODUCT] could cause side effects.
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You do not have to join this investigational treatment protocol. You could choose to
receive standard methods to [PREVENT or TREAT] [NAME OF DISEASE]. We
will give you details about the purposes, procedures, risks and possible benefits
related to this protocol. We will explain other choices that you have. We will also
give you any other information that you need in order to make an informed decision
about joining this protocol.
Following is a more complete description of this investigational treatment protocol.
Please read this description carefully. Afterwards, you can ask questions that will help
you decide whether to join the protocol. If you join this investigational treatment
protocol, we would give you a signed copy of this form to keep for future reference.
You are free to say “yes” or “no” to being in this investigational treatment protocol,
or to drop out after joining. If you say “no,” you would have no penalty or loss of
benefits. Whatever you decide, your regular medical care would not change.
Why are we doing this protocol?
This investigational plan is for treatment with [NAME THE INVESTIGATIONAL
PRODUCT]. [BRIEFLY DESCRIBE THE INVESTIGATIONAL PRODUCT, ITS
USE IN PATIENT’S DISEASE, CURRENT STATUS OF DRUG
DEVELOPMENT, ETC.]
You cannot receive [NAME THE INVESTIGATIONAL PRODUCT] outside of this
protocol because [REASON/STATUS (E.G., IT IS OFF THE MARKET; IT IS NOT
APPROVED BY THE U.S. FOOD AND DRUG ADMINISTRATION; YOU ARE
NOT ELIGIBLE FOR ANY OTHER RESEARCH STUDIES USING THE DRUG,
ETC.)]. The U.S. Food and Drug Administration (FDA) requires an investigational
treatment protocol in order for us to give you [NAME THE INVESTIGATIONAL
PRODUCT]. [MANUFACTURER], the company that makes [NAME THE
INVESTIGATIONAL PRODUCT], has agreed to provide [NAME THE
INVESTIGATIONAL PRODUCT] for this protocol.
We think that this investigational plan might help treat your disease, but there is no
guarantee that it will help. Your disease could stay the same or get worse, and
receiving [NAME THE INVESTIGATIONAL PRODUCT] has risks that are described
later in this consent form.
What tests, procedures, and treatments are done in this investigational
treatment plan?
Describe treatment plan. If possible, use bulleted lists, tables, etc., for readability, as with any
other consent form. Include any non-standard tests/procedures that will be done before or after
treatment with the investigational drug.
If you join this treatment plan, we would do these tests and procedures:

[NAME OF PROCEDURE]. [BRIEF DESCRIPTION].
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0000 [CENTER CANCER CONSORTIUM PROTOCOL NUMBER]


[NAME OF PROCEDURE]. [BRIEF DESCRIPTION].
[NAME OF PROCEDURE]. [BRIEF DESCRIPTION].
You may have other tests and procedures as part of your regular cancer care
How long would you stay in this investigational treatment protocol?
FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: Define total expected time, and
then break down into treatment and follow-up as appropriate. If there are procedures or
consequences for early withdrawal, state them clearly.
If you join this treatment plan, you would stay in this protocol [for or until] about
[TIMEFRAME OR EVENT].
You would receive [NAME OF INVESTIGATIONAL PRODUCT] for
[DURATION]. After that, you would have follow-up exams in the office or clinic
every [INTERVAL TIME] for [DURATION].
Doctors could take you out of this treatment plan at any time. This would happen if:

They think it is in your best interest to stop the treatment or change to a
different treatment.

You not able or willing to follow procedures.

[NAME THE INVESTIGATIONAL PRODUCT] becomes unavailable.

[NAME THE INVESTIGATIONAL PRODUCT] becomes available without
an investigational treatment plan.

The treatment plan has to be stopped for other reasons
If you are thinking about stopping this investigational treatment protocol, please tell
the doctor in charge. The doctor can tell you about the effects of stopping treatment
and about whether follow-up procedures or testing are recommended.
What are the side effects (risks)?
In this part of the consent form, we describe the side effects we expect from the tests
and treatments in this investigational treatment plan. [NAME OF
INVESTIGATIONAL PRODUCT] could cause side effects we do not know about
yet. We will carefully watch you for side effects.
If you join the treatment plan, we would tell you if we discover new side effects that
could affect you.
You should tell your doctor about any side effects that you have or any change in how
you feel during this treatment plan. Side effects may be mild or very serious.
Medicines could be given to help lessen side effects. Many side effects go away soon
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0000 [CENTER CANCER CONSORTIUM PROTOCOL NUMBER]
after you stop taking [INVESTIGATIONAL PRODUCT]. In some cases, side effects
can last a long time or never go away. There also is a risk of death.
FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: Describe any foreseeable risks,
stresses or discomforts to be expected. If a side effect may be irreversible, long-term or life
threatening, say so. Do not state that there are no risks.
If applicable, divide risks into likely, less likely, and rare but serious. There are no standard
definitions for these categories. As a guideline, “likely” can be viewed as occurring in > 20% of
patients and “less likely” in < 20% of patients. Adjust these levels for specific study agents.
Sample language for specific drug risks is available in the NCI website ;
http://ctep.cancer.gov/protocolDevelopment/sideeffects/drugs.htm.
In the “likely” and “less likely” categories, identify those side effects that may be ‘serious’.
‘Serious’ is defined as side effects that may require hospitalization or may be irreversible, longterm, life-threatening, or fatal.
Side effects that occur in < 3% of participants do not have to be listed unless they are serious,
and should then appear in the “rare but serious” category.
Side effects of [NAME THE INVESTIGATIONAL PRODUCT]:
[IF KNOWN, STATE PREVIOUS HUMAN EXPERIENCE WITH DRUG – E.G.,
“DRUG HAS BEEN GIVEN TO ABOUT 800 PATIENTS WITH DISEASE, AND
THE FOLLOWING SIDE EFFECTS HAVE BEEN SEEN:”]
Likely (>[#]% of patients)
Less likely ([#]-[#]%)
Rare but serious (<[#]%)
[ITEM]
Likely side effects of [ITEM] are:

[ITEM].

[ITEM].
Less likely side effects of [ITEM] are:

[ITEM].

[ITEM].
Rare but serious side effects of [ITEM] are:

[ITEM].

[ITEM].
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0000 [CENTER CANCER CONSORTIUM PROTOCOL NUMBER]
Side effects of other drug or procedure [(REPEAT AS NEEDED)]:
Likely (>[#]% of patients)
Less likely ([#]-[#]%)
Rare but serious (<[#]%)
[ITEM]
Likely side effects of [ITEM] are:

[ITEM].

[ITEM].
Less likely side effects of [ITEM] are:

[ITEM].

[ITEM].
Rare but serious side effects of [ITEM] are:

[ITEM].

[ITEM].
Radiation risks
Delete this section if not needed.
[Insert appropriate language from Radiation Safety Office]
Reproductive risks
Delete this section if not needed. Limit information to what is appropriate for the specific patient
(for example, a woman of childbearing age).
Chemotherapy and radiation treatments could cause sterility (unable to have
children).
When appropriate, include a statement that if the participant was or became pregnant, the
particular treatment or procedure might involve risks to the embryo or fetus, which were currently
unforeseeable. Appropriate when the investigational treatment protocol involves a woman of
childbearing potential and the risk to fetuses of the drugs, devices, or other procedures involved
is not well known.
Paragraphs 1-3 below are for a FEMALE patient of childbearing potential. Paragraph 4 (last
paragraph) is for a MALE patient.
Taking [NAME OF INVESTIGATIONAL PRODUCT] may involve unknown risks
to an embryo fetus (unborn baby) or nursing infant. Therefore, you could not join this
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0000 [CENTER CANCER CONSORTIUM PROTOCOL NUMBER]
treatment plan if you are pregnant, if you are planning to become pregnant, or if you
are breast-feeding.
If you join this treatment plan, you would have to use an effective method of birth
control from the time this form is signed until at least [DURATION] after the last
dose of [NAME OF INVESTIGATIONAL PRODUCT]. If you are already using a
method of birth control, you would have to check with the doctor or a member of the
treatment staff to make sure it is acceptable.
If you became pregnant after joining this treatment plan, you would have to notify the
doctor immediately. Participation in this treatment plan would end, and you would
receive counseling and follow up throughout the pregnancy and for about 6 months
after the child is born.
The effects of [NAME OF INVESTIGATIONAL PRODUCT] on fathering a child
are unknown. If you join this treatment plan, you must agree to use one or more forms
of effective and acceptable birth control from the time this form is signed until at least
[DURATION] after the last dose of [NAME OF INVESTIGATIONAL PRODUCT].
What are the benefits?
We do not know if this investigational treatment plan would help you. It is possible
that [NAME THE INVESTIGATIONAL PRODUCT] may reduce the disease in your
body and improve any symptoms that you may have from your disease.
You have other choices besides this investigational treatment protocol.
You do not have to join this investigational treatment plan. You are free to say “yes”
or “no”. Your regular medical care would not change if you decide to say “no”.
You have other choices for treatment. Each of these choices has risks and benefits.
You should talk to your doctor or healthcare provider about these choices.
Other choices include: [DESCRIBE ALTERNATE OPTIONS e.g. Standard
Treatment, a Research Study, No Treatment, Comfort Care].
Enrollment in this treatment plan may exclude you from some research studies.
Protecting Privacy as an Individual and the Confidentiality of Personal
Information
If you join this treatment plan, some people or organizations might need to look at
your medical records for quality assurance or information about your treatment on the
investigational plan. They include:

Doctors and other individuals involved with this investigational treatment
plan.
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
[MANUFACTURER], the company that is providing [NAME THE
INVESTIGATIONAL PRODUCT].

Institutional Review Boards (IRB), including the Fred Hutchinson Cancer
Research Center IRB. An IRB is a group that reviews research studies and
investigational treatment protocols to protect the rights and welfare of
participants.

Fred Hutchinson Cancer Research Center, University of Washington, Seattle
Children’s, and Seattle Cancer Care Alliance [REMOVE ANY
INSTITUTIONS THAT ARE NOT INVOLVED].

US National Institutes of Health, National Cancer Institute, Office for Human
Research Protections, Food and Drug Administration, and other regulatory
agencies as required.
We will do our best to keep personal information confidential. But we cannot
guarantee total confidentiality. Personal information may be given out if required by
law. For example, workplace safety rules may require health workers to contact you
about lab tests. Or a court may order information to be disclosed. Such cases are rare.
We will not use personal information in any reports about this investigational
treatment, such as journal articles or presentations at scientific meetings.
If you join this investigational treatment plan, information about your participation
would be made part of your permanent medical record. This information would
include a copy of this consent form. If you authorize others to see your medical
record, they would see a copy of this consent form.
Would we pay you if you join this investigational treatment protocol?
There is no payment for being in this investigational treatment plan.
Would you have extra costs if you join this investigational treatment
protocol?
FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: State protocol-specific information
about costs to participants. Inclusion of additional costs to the participant that may result from
participation is appropriate when it is anticipated that participants may have additional costs.
One approach is to state that there are some extra costs, and list everything (tests, procedures,
agents, etc.) that is NOT covered. Another approach is to state that participant or insurer will have
to pay costs except for those listed, and list everything that IS covered. Various examples are
given here. Edit as needed.
There are no extra costs for being in this investigational plan.
OR
If you join this investigational plan, you would have some extra costs. Your insurance
company might pay these costs, but some insurance policies do not cover
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investigational treatments. We could help find out whether your insurance company
would cover these costs.
The extra costs are:
Choose all that apply and delete the rest:

Cost of tests that are given more often than usual.

Cost of [NAME OF INVESTIGATIONAL PRODUCT].

Paying the people who give [NAME OF INVESTIGATIONAL PRODUCT],
and the cost of the equipment they use.

Cost of people and equipment to give [NAME OF INVESTIGATIONAL
PRODUCT]. There is no charge for [NAME OF INVESTIGATIONAL
PRODUCT] itself.

Cost of standard doctor visits and lab tests.

Cost of any other medical care needed because of this investigational
treatment plan.
If you join this investigational treatment plan, you or your insurance company would
have to pay for the costs of standard treatment.
You would not be billed for:

[ITEM].

[ITEM].
If [NAME OF INVESTIGATIONAL PRODUCT] is approved as a treatment while
you are still receiving it, you or your insurance company might have to pay for
[NAME OF INVESTIGATIONAL PRODUCT] so you can continue treatment.
What if you get sick or hurt after you join this investigational treatment
protocol?
FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: All consent forms must describe
any compensation for injury available to participants.
For studies where the sponsor does not provide compensation (e.g. NIH funded studies) the
following 3 paragraphs must be included in the consent:
If the protocol has a Sponsor who has agreed to pay for treatment related injury, revise the
wording in paragraphs two and three as necessary per the Clinical Trial Agreement. E.g. industry
sponsored studies, or other sponsors who may offer compensation for injury.
For a life threatening problem, call 911 right away or seek help immediately. Contact
your doctor when the medical emergency is over or as soon as you can.
For all other medical problems or illness related to this protocol, immediately contact
[FILL IN AS APPROPRIATE]. They will treat you or refer you for treatment. You
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or your health insurance will have to pay for the treatment. There are no funds to pay
you for an investigational treatment plan-related injury, added medical costs, loss of a
job, or other costs to you or your family. State or national law may give you rights to
seek payment for some of these expenses. You do not waive any right to seek
payment by signing this consent form.
You or your insurer will be billed for treatment of problems or complications that
result from your condition or from standard clinical care.
You would not lose any legal right to seek payment for treatment if you sign this
form.
Your rights

You do not have to join this investigational treatment plan. You are free to say
“yes” or “no”.

If you get sick or hurt in this treatment plan, you do not lose any of your legal
rights to seek payment by signing this form.

During the treatment plan, we might learn new information that you need to
know. For example, some information may affect your health or well-being.
Other information might make you change your mind about being in this
treatment plan. If we learn these kinds of information, we would tell you.

If you join this treatment plan, you would not have to stay in it. You could
stop at any time (even before you start). Your regular medical care would not
change. You would have no penalty for stopping, but it would be better not to
start the treatment plan if you think that you would change your mind later.
FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: When appropriate, explain the
consequences of a participant’s decision to withdraw from the investigational treatment plan.
Appropriate when withdrawal is associated with adverse consequences.
When appropriate, explain procedures for orderly termination of participation by the participant.
Appropriate when the treatment includes such procedures.

If you decide to drop out, we would want you to tell the doctor. The doctor
could tell you about the effects of stopping [NAME OF INVESTIGATIONAL
PRODUCT]. You and the doctor could talk about the follow-up care and
testing that would help the most.
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Your responsibilities
If you join this investigational treatment plan, you would have some responsibilities.

Follow the schedule of visits and procedures.

Take medications as directed.

[PREVENT PREGNANCY].

Tell us about side effects.
For more information
If you have questions or concerns about this treatment plan, you could talk to your
doctor anytime. Other people you could talk to are listed below.
FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: In the table below, include both
FHCRC and UW contact information if this is a UW Consortium protocol. If Fred Hutch remove
Human Subjects Division.
If you have questions about:
Call:
This treatment plan (including
complaints and requests for
information)
[000-000-0000] (Dr. [full name of PI])
[000-000-0000] ([name and title of staff contact])
If you get sick or hurt in this
treatment plan
[000-000-0000] (Dr. [surname of PI])
Your rights as a participant
206-667-4867 (Karen Hansen, Director of
Institutional Review Office, Fred Hutchinson Cancer
Research Center)
206-543-0098 (Human Subjects Division, University
of Washington)
Your bills and health insurance
coverage
[000-000-0000]
Emergency number (24 hours): [000-000-0000]
[INSTRUCTIONS FOR EMERGENCY NUMBER, IF NEEDED –
E.G., PAGING OPERATOR]
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This signature page is the basic choice for an English-reading adult participant. See following
pages for additional instructions from FHCRC model consent template, to include as needed
Signatures
If you have read this form (or had it read to you), asked any questions, and agree to
participate, please sign:
Participant/ Printed Name, Signature, and Date
Clinical Investigator’s statement
I have discussed the investigational treatment plan, including procedures and risks,
with the person signing above. A copy of the signed consent form will be given to the
participant.
Person obtaining consent signature / Printed Name, Signature, and Date
Protocol:
Current version date:
Previous version date:
Copies to: Patient, Medical Records
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0000 [CENTER CANCER CONSORTIUM PROTOCOL NUMBER]
Signatures [REQUIRING PARENT/GUARDIAN]
If you have read this form (or had it read to you), asked any questions, and agree to
participate, please sign:
Participant (age 14+) / Printed Name, Signature, and Date
Parent or legal guardian / Printed Name, Signature, and Date
Clinical Investigator’s statement
I have discussed the investigational treatment protocol, including procedures and
risks, with the person signing above. A copy of the signed consent form will be given
to the participant.
Person obtaining consent signature / Printed Name, Signature, and Date
Protocol: 0000
Current version date: XX/XX/XXXX
Previous version date:
Copies to: Patient, Medical Records
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Signatures [REQUIRING LEGALLY AUTHORIZED REPRESENTATIVE]
Legally Authorized Representative: If you have read this form (or had it read to you),
asked any questions, and consent on behalf of the participant, please sign:
Legally authorized representative / Printed Name, Signature, and Date
Relation to the participant
Clinical Investigator’s statement
I have discussed the investigational treatment protocol, including procedures and
risks, with the person signing above. A copy of the signed consent form will be given
to the participant.
Person obtaining consent signature / Printed Name, Signature, and Date
Protocol: 0000
Current version date: XX/XX/XXXX
Previous version date:
Copies to: Patient, Medical Records
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FROM THE FHCRC MODEL CONSENT FORM TEMPLATE: Include a Witness signature line
on your consent only if witness signature is required by regulations (e.g., physical incapacity to
read or write English or difficulty with English language comprehension), IRB directive, or
agreement with sponsor.
If you served as an interpreter or witness during the consent process, sign below to
indicate you attest to the accuracy of the presentation to the participant and the
apparent understanding of the protocol by the participant.
Witness or Interpreter / Printed Name, Signature, and Date
Protocol: 0000
Current version date: XX/XX/XXXX
Previous version date:
Copies to: Patient, Medical Records
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