UK Children's Diabetes Research

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UK GRID: form for mother consenting on behalf of child

                                                  local hospital headed paper

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

CONSENT FORM
(Mother for child's participation)

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 child's participation is voluntary and that       [  ]
   he/she is free to withdraw at any time, without giving any reason,
   without his/her medical care or legal rights being affected in any
   way.

3. I give my consent to the use of his/her 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 my child or his/her heirs
   and without specific acknowledgement of their 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 the taking of blood and urine samples from my       [  ]
   child.

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 my child's participation 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