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U.S. National Institutes of Health
Last Updated: 03/05/10

**Name of Tissue Repository**
address and phone number

Consent Form for Use of Tissue For Research

About Using Tissue for Research

You are going to have a biopsy (or surgery) to see if you have cancer. Your doctor will remove some body tissue to do some tests. The results of these tests will be given to you by your doctor and will be used to plan your care.

We would like to keep some of the tissue that is left over for future research. If you agree, this tissue will be kept and may be used in research to learn more about cancer and other diseases. Please read the information sheet called “How is Tissue Used for Research” to learn more about tissue research.

Your tissue may be helpful for research whether you do or do not have cancer. The research that may be done with your tissue is not designed specifically to help you. It might help people who have cancer and other diseases in the future.

Reports about research done with your tissue will not be given to you or your doctor. These reports will not be put in your health record. The research will not have an effect on your care.

Things to Think About

The choice to let us keep the left over tissue for future research is up to you. No matter what you decide to do, it will not affect your care.

If you decide now that your tissue can be kept for research, you can change your mind at any time. Just contact us and let us know that you do not want us to use your tissue. Then any tissue that remains will no longer be used for research.

In the future, people who do research may need to know more about your health. While the xyz may give them reports about your health, it will not give them your name, address, phone number, or any other information that will let the researchers know who you are.

Sometimes tissue is used for genetic research (about diseases that are passed on in families). Even if your tissue is used for this kind of research, the results will not be put in your health records.

Your tissue will be used only for research and will not be sold. The research done with your tissue may help to develop new products in the future.

Benefits

The benefits of research using tissue include learning more about what causes cancer and other diseases, how to prevent them, and how to treat them.

Risks

The greatest risk to you is the release of information from your health records. The xyz will protect your records so that your name, address, and phone number will be kept private. The chance that this information will be given to someone else is very small.

Making Your Choice

Please read each sentence below and think about your choice. After reading each sentence, circle “Yes” or “No”. No matter what you decide to do, it will not affect your care. If you have any questions, please talk to your doctor or nurse, or call our research review board at IRB's phone number.

1. My tissue may be kept for use in research to learn about, prevent, or treat cancer.

Yes No

2. My tissue may be kept for use in research to learn about, prevent or treat other health problems (for example: diabetes, Alzheimer's disease, or heart disease).

Yes No

3. Someone from xyz may contact me in the future to ask me to take part in more research.

Yes No

Please sign your name here after you circle your answers.

Your Signature: ______________________________________ Date:______________

Signature of Doctor/Nurse: ______________________________

Date:______________