UK Children's Diabetes Research

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UK GRID: children under 16 consenting for themselves

                                                  local hospital headed paper

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

CONSENT FORM
(Children under 16)

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 have had an opportunity to read the information sheet dated           [  ]
   12/02/01 (version 1) for this study and have had the opportunity to ask
   my doctor or nurse questions.

2. I understand that I am free to choose whether I join the study.  If     [  ]
   I change my mind at a later stage and I do not want to be part of the
   study anymore, I will not have to give a reason and it will not affect
   my treatment or visits to the clinic.

3. I understand that the doctors working on my blood sample as part of     [  ]
   their study of genes will not know my name, and they will not be able
   to send me the results of my tests, but they will let me know what they
   find in all the 10,000 samples collected.  They may use this
   information to develop drugs which could help young people with
   diabetes in the future.  I would not know whether my blood was any more
   helpful than anyone else's in this search.

4. I understand that I will have to give blood and urine samples as        [  ]
   part of this study.

5. I understand that if I change my mind at a later date and drop out      [  ]
   of the study, I can ask for my blood and urine samples to be
   destroyed.

6. I am happy to take part in the above study.                             [  ]





_____________________________    ________________    ____________________
Name of patient                  Date                Signature



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


_____________________________    ________________    ____________________
Researcher                       Date                Signature

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