UK Children's Diabetes Research

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UK GRID: mothers' consent form

                                                  local hospital headed paper

Centre LREC Number:
Study Number: 00/5/65
Patient Identification Number for this trial:

CONSENT FORM
(Mother)

Title of Project: The Genetics of Diabetic Nephropathy


Name of Researcher: Professor David B Dunger, Professor John Todd, Cambridge

Local investigator: ________________________________________

                                                            Please initial box

1. I confirm that I have read and understand the information sheet dated  [  ]
   05/01/01 (version 2) for the above study and have had the opportunity
   to ask questions.

2. I understand that my participation is voluntary and that I am free to  [  ]
   withdraw at any time, without giving any reason, without my medical
   care or legal rights being affected in any way.

3. I give my consent to the use of my blood sample for genetic studies    [  ]
   into the causes of diabetes and its complications (commercial or
   non-commercial).  I realise that the investigators will make
   immortalised cell lines from which DNA, RNA and protein will be
   prepared for further study by research groups interested in these
   areas.  I understand that any information which comes from this work
   may be the subject of a future patent application or be used for
   commercial purposes, without any payment to me or my heirs and without
   specific acknowledgement of my contribution.  I understand that I do
   not have any rights over the sample or information that comes from that
   sample or cell line.

4. I give consent for blood and urine samples to be taken for this        [  ]
   study.

5. If at a subsequent date I want to revoke my consent for these          [  ]
   studies, then I understand that if I request it, the sample or cell
   line will be destroyed.

6. I agree to take part in the study.                                     [  ]





_____________________________    ________________    ____________________
Name of volunteer                Date                Signature



_____________________________    ________________    ____________________
Name of Person taking consent    Date                Signature
(if different from researcher)                                                 


_____________________________    ________________    ____________________
Researcher                       Date                Signature

    1 for volunteer; 1 for researcher; 1 to be kept with hospital notes