The University of Texas Southwestern Medical Center at Dallas
CONSENT TO PARTICIPATE IN RESEARCH
Short Screening Consent
Title of Research: Physical and Metabolic Abnormalities in Lipodystrophy and Dyslipidemias
Sponsor: NIH
Telephone No.(other times)
Investigators
Telephone No(regular office hours)
Abhimanyu Garg, M.D.
Vinaya Simha, M.D.
Peter Snell, Ph.D.
Paul Weatherall, M.D.
Claudia Quittner, RN
David Euhus, M.D.
Meena Shah, Ph.D.
Dolores Peterson, M.D., Ph.D.
Zahid Ahmad, M.D.
Ron Hoxworth, M.D.
214-648-2895
214-648-4773
214-648-9187
214-648-5812
214-648-9296
214-648-6467
214-648-6874
214-648-3246
214-648-0548
214-645-2353
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590--7781
INVITATION: Note: If you are a parent or guardian of a minor and have been asked to read and sign
this form, the “you” in this document refers to the minor.
Instructions:
Please read this consent form carefully and take your time making a decision about whether to
participate. As the researchers discuss this consent form with you, please ask him/her to explain
any words or information that you do not clearly understand. The purpose of the study, risks,
inconveniences, discomforts, and other important information about the study are listed below. If
you decide to participate, you will be given a copy of this form to keep.
You are invited to participate in this research because either you or your child or your family
members have abnormalities of fat cells and metabolism, disorders such as lipodystrophy (either
congenital-generalized, familial-partial, or acquired lipodystrophy). Or you have another type of
body fat disorder involving problems with fat or sugar metabolism including abnormal blood fats
(triglycerides and/or cholesterol) or and other syndromes which may be related, such as premature
aging syndromes, obesity or lipomatosis. Also, you may qualify if you have lipodystrophy with HIV.
You may also participate as a normal volunteer if you do not show signs of lipodystrophy or body
fat abnormalities, in order to serve as part of a comparison group.
This study does not offer a treatment or intervention for your condition.
NUMBER OF PARTICIPANTS: The sponsor plans to include 1800 participants in this research.
PURPOSE:
You have been asked to undergo a blood test and possibly other tests that will help
determine if you have any metabolic disorders such as high blood cholesterol, triglycerides or
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glucose associated with lipodystrophy (a disease of abnormal body fat distribution), or other types
of disorders involving problems with fat or sugar metabolism and other syndromes which may be
related, such as premature aging syndromes.
The overall purpose of this research is to examine the physical and metabolic defects associated
with lipodystrophy and related syndromes and learn how these develop.
PROCEDURES
Screening: You will be asked questions about your health and health history, there will be
questionnaires about your body shape changes and quality of life and you may have a physical
exam.
You will have blood tests, and you may have urine tests and measures of height, weight and body
fat (anthropometry). These procedures are being done because you are in this research.
Your photographs may also be requested from you or your physician prior to your evaluation here,
or we may take photographs while you are here. We use photographs for diagnostic, research and
educational purposes. Your photographs may be taken by a professional photographer or a member
of Dr. Garg’s research team and they may be published in professional scientific journals or
medical books but your identity will not be disclosed if any images are published.
How long can I expect to be in this study?
For this study, you may be seen just once, or yearly or every few years or if your body shape or
metabolism changes, or at an interval of your choosing. If you have been seen and then months or
years later we develop a new study that might help you, we would contact you to see if you would
like to participate. Unless you tell us not to contact you in future, or not to contact you after a
certain period of time.
You can choose to stop participating for any reason at any time. However, if you decide to stop
participating in the study, we encourage you to tell the researchers.
Evaluations during the research:
INVESTIGATIONAL PROCEDURES: The tests with their known risks are listed below. The
investigator obtaining this consent from you will check the boxes for the tests you are being asked
to undergo. You should read the description of the requested tests and their associated risks.
After you understand the tests and risks fully, you will be asked to check in the boxes yes or no if
you agree or not for each of the requested tests. Then place your initials where indicated. And
you will be asked to sign the consent on the last page.
For children, the blood draw amounts for all the testing will be based on the child's weight and
will usually be smaller amounts than those shown for adults.
1.
Blood tests, the risks of donating this blood are minimal but include: (1) a lightheaded or dizzy
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feeling while the blood is being drawn, and
drawn or very rarely infection.
I consent to the following blood tests:
a bruise or soreness at the site where the blood was
The blood tests are for:
Cholesterol, triglyceride, lipoprotein, and hormone
(Insulin, leptin, sex hormones, etc.) analysis:
2-4 teaspoons.
YES
NO
INITIALS
__
___
__
SMAC-20 (general blood chemistry screen) and/or CBC: (3 to 4 teaspoons).
------
------
-----
Apolipoprotein (proteins related to blood cholesterol) analysis:
(2 tablespoons or 6 teaspoons).
------
------
------
Glycosylated hemoglobin A1c (tests for diabetes): (1 teaspoon).
------
-----
-----
Serum protein electrophoresis and/or Thyroid function tests: (2 teaspoons).
------
-----
-----
2. Anthropometry
a. (Height, weight, and percent of body fat measurements):
In order to determine how much muscle and fat is in your body, we will obtain detailed
measurements of height, weight, and skinfold thickness using a tape measure, scale, and calipers
(a fat measuring instrument). You will be weighed and measured while wearing minimal clothing,
such as underwear and a patient gown.
b. Underwater weighing: This test requires that you put on a bathing suit and get into a tub of
lukewarm water. You will be asked to breathe out as much air as you can and go completely under
water for a period no longer than 15-20 seconds. While you are underwater, you will hear the
investigator knock on the side of the tub, and that will be a signal for you to come up for air. Since
it requires breath holding under water, children less than 6 years of age or unable to hold their
breath will not be allowed to do this test.
The risks of anthropometry are only the possible discomfort of holding your breath briefly
underwater or the slight pinching feeling of the calipers, which measure skinfold thickness
ANTHROPOMETRY
_______ YES ______ NO ________ INITIALS
3. OGTT, Oral Glucose Tolerance Test:
OGTT, Oral glucose tolerance test:: For this test you will have an intravenous (IV) line placed
for blood drawing and then receive a sugar drink on an empty stomach in the morning. Blood
will be taken from the IV line at 30 minute intervals for 3 hours to check your glucose and
insulin response. The total amount of blood drawn for adults will be 45 ml. This is 3
tablespoons.
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The risks of oral glucose tolerance test are the risks of a blood draw or the brief
placement of an IV line, bruising, feeling light-headed or dizzy or possible
infection, also rarely the sweet drink causes nausea.
OGTT
_____ YES ______ NO
______ INITIALS
4. Dietary Recall:
You will be asked about your food intake with a 1 or 3-day food recall or 3
day food record questionnaire, or by interview or phone interview. You may be called by Dr. Shah
or her research assistant to give you additional
instructions on completing the food record. This
takes up 30 minutes or more of your time. Although careful precautions are taken to protect your
privacy, there is an outside chance that an unauthorized person could review your information.
DIETARY RECALL
_____ YES _____ NO _____ INITIALS
POSSIBLE BENEFITS
Benefit to you: A benefit you may receive from having these tests is the knowledge that you either
do or do not have a metabolic disorder associated with lipodystrophy or a related syndrome. If we
discover that you do have a metabolic disorder, proper therapy to control the condition can be
instituted, either through our clinic or by your physician.
Benefit to other people with lipodystrophy, premature aging or related syndromes:
In the future, other people with lipodystrophy, premature aging or other problems related to
abnormal fat or glucose metabolism or unusual fat distribution could benefit from the results of
this research. Information gained from this research could lead to improved medical care for
them. However, your study doctor will not know whether there are benefits to other people with
lipodystrophy, premature aging and related syndromes until all of the information obtained from
this research has been collected and analyzed.
COSTS TO YOU: The sponsor will pay the expenses for the test that is done including laboratory
work, underwater weight, and oral glucose tolerance test. Expenses related to standard medical
care for your lipodystrophy, HIV, premature aging or other syndromes, diabetes, high triglycerides
and other metabolic abnormalities are your responsibility (or the responsibility of your insurance
provider or government program).
There are no funds available to pay for parking expenses, transportation to and from the research
center, lost time away from work and other activities, lost wages, or child care expenses.
COMPENSATION FOR INJURY: Compensation for an injury resulting from your participation in this
research is not available from the University of Texas Southwestern Medical Center at Dallas or
Parkland Health & Hospital System,.
You retain your legal rights during your participation in this research.
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Study ID: STU 082010-274 Date Approved: 10/22/2010 Expiration Date: 10/3/2011
VOLUNTARY PARTICIPATION IN RESEARCH: You have the right to agree or refuse to participate in
this research. If you decide to participate and later change your mind, you are free to discontinue
participation in the research at any time.
Refusal to participate will involve no penalty or loss of benefits to which you are otherwise
entitled. Refusal to participate will not affect your legal rights or the quality of health care that
you receive at this center.
Your status as a medical student, fellow, faculty, or staff in the medical center will not be
affected in any way.
NEW INFORMATION: Any new information which becomes available during your participation in
the research and may affect your health, safety, or willingness to continue in the research will be
given to you.
RECORDS OF YOUR PARTICIPATION IN THIS RESEARCH:
You have the right to privacy. Any information about you that is collected for this research will
remain confidential as required by law. In addition to this consent form, you will be asked to sign
an “Authorization for Use and Disclosure of Protected Health Information for Research Purposes,”
which will contain more specific information about who is authorized to review, use, and/or
receive your protected health information for purposes of the study.
YOUR QUESTIONS: Your study doctor is available to answer your questions about this research.
The Chairman of the IRB is available to answer questions about your rights as a participant in
research or to answer your questions about an injury or other complication resulting from your
participation in this research. You may telephone the Chairman of the IRB during regular office
hours at 214-648-3060.
YOU WILL HAVE A COPY OF THIS CONSENT FORM TO KEEP.
Your signature below certifies the following:
• You have read (or been read) the information provided above.
• You have received answers to all of your questions.
• You have freely decided to participate in this research.
• You understand that you are not giving up any of your legal rights.
__________________________________________________
Participant’s Name (printed)
__________________________________________________
Participant’s Signature
__________________________________________________
Legally authorized representative’s name (printed)
__________________________________________________
Legally authorized representative’s Signature
_______________
Date
________________
Date
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Study ID: STU 082010-274 Date Approved: 10/22/2010 Expiration Date: 10/3/2011
__________________________________________________
Name (printed) of person obtaining Consent
__________________________________________________
Signature of person obtaining consent
________________
Date
ASSENT OF A MINOR:
I have discussed my participation in this research with my mother or father or legal guardian and
my study doctor, and I agree to participate in this research.
_________________________________________
Signature (participants from 10 to 18 years old)
___________________
Date
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Study ID: STU 082010-274 Date Approved: 10/22/2010 Expiration Date: 10/3/2011
The University of Texas Southwestern Medical Center at Dallas
CONSENT TO PARTICIPATE IN RESEARCH
TITLE OF RESEARCH: Physical and Metabolic Abnormalities in Lipodystrophy and
Dylipidemias
SPONSOR: National Institutes of Health
INVESTIGATORS:
Abhimanyu Garg, M.D.
Vinaya Simha, M.D.
Peter Snell, Ph.D.
Paul Weatherall, M.D.
Claudia Quittner, RN
David Euhus, M.D.
Meena Shah, Ph.D.
Dolores Peterson, M.D., Ph.D.
Zahid Ahmad, M.D.
Ron Hoxworth, M.D,
Telephone No. (office hours)
214-648-2895
214-648-4773
214-648-9187
214-648-5812
214-648-9296
214-658-6467
214-648-6874
214-648-3246
214-648-0548
214-645-2353
Telephone No. (other times)
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
214-590-7781
INVITATION: You are invited to participate in this research because either you or your family
members have adipose tissue disorders such as lipodystrophy (either congenital-generalized, familialpartial, or acquired lipodystrophy). Or you have another type of body fat disorder involving problems
with fat or sugar metabolism including abnormal blood fats
(Triglycerides and/or cholesterol) or and other syndromes which may be related, such as premature
aging syndromes, obesity or lipomatosis. Also, you may qualify if you have lipodystrophy with HIV.
You may also participate as a normal volunteer if you do not show signs of lipodystrophy or body fat
abnormalities, in order to serve as part of a comparison group.
NUMBER OF PARTICIPANTS: Dr. Garg plans to include 1800 participants in this research.
PURPOSE: Dr. Garg wants to learn more about lipodystrophy and other disorders where there are
problems with glucose or fat metabolism, including premature aging syndromes. This research is
necessary because there is currently not much information available about these problems.
PROCEDURES
For this part of the research, you may be asked for a blood sample, a tissue sample, or both.
Sample of blood: A doctor, nurse, or licensed technician will collect 4-6 teaspoons ( 20-30ml) of blood
by vein one time. We may ask for a second blood sample if the research laboratory cannot process
the first sample. The samples will be coded with a unique identifier. This code is based upon the
suspected diagnosis and order of presentation to us. This identifier is not kept in your hospital chart.
Cells removed during surgery: If you are planning to have surgery for any reason and we are able
to coordinate with your surgeon, we may ask to keep some cells already removed during surgery for
this research.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
Sample of Tissue: For some subjects a tissue biopsy will be requested. This will involve a skin,
muscle, or fat biopsy collected for this research. A skilled physician will perform the procedure.
Adipose Tissue Biopsy (Fat Biopsy):
For this procedure done under sterile conditions, a 2"x 2" area of your skin will be numbed with
the anesthetic lidocaine. A small incision ( 1 ½ inches or less) will be made in the skin, and a
small piece of fat (about the size of a marble containing about 5-10 grams of fat) will be
removed from under your skin. Cautery may be used to decrease the risk of bruising. The
incision will be closed using dissolvable sutures and steri-strips or skin adhesive. Biopsies will
be taken from one or two sites, most likely sites are the back of the neck, the abdomen and the
upper thigh, if you develop fat accumulations at different sites we may request you allow a
biopsy from an alternate or additional site. The tissue obtained by this procedure will be used
to determine anatomical and biochemical changes in the fat tissue. Children less than 14
years of age will not have this procedure.
Muscle Biopsy:
If this is a punch biopsy then a small area of skin will be cleaned then numbed with lidocaine,
and a tiny incision will be made. A needle will be inserted into your muscle through the incision
and a very tiny pea-sized piece of muscle will be withdrawn through the needle (about 200mg).
If this is being done as part of a fat biopsy then the procedure is as described for the adipose
tissue (fat biopsy) above, the only difference is that the surgeon will also remove a tiny peasized piece of muscle through the incision already created to remove the fat. Cautery will be
used to minimize bruising. The site will be closed with dissolvable sutures and steri-strips or
skin adhesive. The tissue will be used to determine anatomical and biochemical changes in
the muscle tissue. Children less than 16 years of age will not have this procedure.
Skin Biopsy:
For this procedure one inch by one-inch area of your skin will be cleaned and numbed with the
anesthetic lidocaine. A small round piece of skin about 1/16th inch across will be removed with
a punch biopsy instrument. The wound will be closed with steri-strips or skin adhesive and no
sutures will be needed. The cells from the skin sample will be grown in culture and
anatomical, biochemical and biological changes in these cells will be determined. Children
less than 4 years of age will not have this procedure.
For more information about the use of your blood or tissue sample in this research, please
read “More Information about This Research” at the end of this consent form.
POSSIBLE RISKS
Questions: We will ask you personal questions. However, you can skip any question that makes you
uncomfortable.
Sample of blood: You may experience discomfort, bleeding, and/or bruising. You may feel dizzy or
faint. On a rare occasion, an infection could develop at the site where the blood was collected.
Sample of Tissue:
Adipose Tissue Biopsy:
The biopsy site could bleed or form hematoma (collection of blood in tissue), or a bruise. This
procedure is done under sterile conditions. There is a minimal risk for infection at the biopsy
sites. You could have an allergic reaction to the skin cleanser or to the local anesthetic.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
Please tell the study nurse and doctors if you know that you are allergic to betadine, iodine,
novocaine or lidocaine. You will have small scars where the incisions are made. You may
experience pain during or after the procedure. It is possible that a nerve in your skin might be
damaged or cut, causing temporary or permanent numbness in a patch of skin near the
incision.
Muscle Biopsy:
The biopsy site is the adipose tissue biopsy site and the risks are the same as above. There
may be pressure or pain during or after the procedure, although a local anesthetic agent is
used. You could develop bruising or a hematoma (collection of blood in the tissue), the site
could bleed. There is a minimal risk for infection at the site. You will have small scars where
the incisions are made.
It is possible that a nerve in your skin might be damaged or cut, causing temporary or
permanent numbness in a patch of skin near the incision.
Skin Biopsy:
There is a small risk for bleeding, bruising, pain or infection. You will have a tiny scar at the
site.
Other risks: The attached document (“More Information about This Research”) describes other
possible risks related to this type of research.
Unforeseen risks: There could be risks to your participation in this research which Dr. Garg does not
know about now.
What to do if you have problems: If you have a medical problem after blood or tissue is collected
for this research, Dr. Garg can recommend treatment. Please report the problem to Dr. Garg or
Claudia Quittner promptly. Call any one of the telephone numbers listed on the first page of this
consent form.
POSSIBLE BENEFITS
To you: Usually there are no personal benefits from participation in this kind of research.
To others: The results of this research may help other people in the future. New information may
lead to improvements in medical care for lipodystrophy, premature aging or related syndromes.
However, research tests using your sample could possibly fail to produce useful information.
COMMERCIAL DEVELOPMENTS: Research tests using your sample may possibly result in
inventions or procedures that have commercial value and are eligible for protection by a patent.
Should future commercial developments occur, there are no plans to provide financial compensation
to you from the University of Texas Southwestern Medical Center at Dallas or its researchers, and/or
other facilities or researchers whose research may benefit from the use of your sample. By agreeing
to the use of your sample in research, you are giving your sample with the understanding that there
are no plans of providing you acknowledgment, compensation, interest in any commercial value or
patent, or interest of any other type. You retain your legal rights during your participation in this
research.
PAYMENT TO TAKE PART IN THIS RESEARCH: You will not be paid to participate in this research.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
COSTS TO YOU: Collecting a sample of blood or tissue and testing it in a research laboratory will
not cost you anything (or your insurance company/government program).
Expenses for routine health check-ups or care for any medical problem are your responsibility (or the
responsibility of your insurance provider or government program).
There are no funds available to pay for parking expenses, transportation to and from the research
center, lost time away from work and other activities, lost wages, or child care expenses.
COMPENSATION FOR INJURY: Compensation for a physical injury or any other complication
resulting from participation in this research is not available from the University of Texas Southwestern
Medical Center at Dallas or Parkland Health & Hospital System, However, you retain your legal rights
during your participation in this research.
VOLUNTARY PARTICIPATION IN RESEARCH: You have the right to agree or refuse to participate
in this research. If you decide to participate and later change your mind, you are free to stop at any
time.
Your refusal to participate will not result in any penalty or loss of benefits to which you are otherwise
entitled. Your refusal to participate will not affect your legal rights or the quality of health care that
you receive at this center.
RECORDS OF YOUR PARTICIPATION IN THIS RESEARCH: You have the right to privacy. Any
information about you that is collected for this research will remain confidential as required by law. In
addition to this consent form, you will be asked to sign an “Authorization for Use and Disclosure of
Protected Health Information for Research Purposes,” which will contain more specific information
about who is authorized to review, use, and/or receive your protected health information for the
purposes of this study.
Certificate of Confidentiality: Dr. Garg has obtained a Certificate of Confidentiality from the Federal
government. This Certificate will help researchers protect your privacy. However, the Certificate will
not protect your privacy if you consent in writing to the release of information about your participation
in this research to anyone else.
For more information about a Certificate of Confidentiality, please read “More Information
about This Research” at the end of this consent form.
YOUR QUESTIONS: Dr. Garg is available to answer your questions about this research.
The Chairman of the IRB is available to answer questions about your rights as a participant in
research or to answer your questions about an injury or other complication resulting from your
participation. You may telephone the Chairman of the IRB during regular office hours at 214-6483060.
YOU WILL HAVE A COPY OF THIS CONSENT FORM TO KEEP.
Your signature below certifies the following:
· You have read (or been read) the information provided in this consent form and in the attached
document, “More Information about This Research.”
· You have received answers to all of your questions.
· You have freely decided to participate in this research.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
· You understand that you are not giving up any of your legal rights.
________________________________________________________
Participant’s name (printed)
________________________________________________________
Participant’s signature and date
________________________________________________________
Legally authorized representative’s name (printed)
_______________________________________________________
Legally authorized representative’s signature and date
________________________________________________________
Name of person obtaining consent (printed)
________________________________________________________
Signature of person obtaining consent and date
ASSENT OF A MINOR:
I have discussed my participation in this research with my mother or father or legal guardian and
[insert name of person obtaining consent], and I agree to participate in this research.
_________________________________________________________
Signature (participants from 10 to 18 years of age) and date
More Information about This Research
What will happen to the samples and information collected for this research? Dr. Garg will
compare information about the health of participants with the results of research tests using their
DNA, cells or tissue.
What is DNA? DNA means deoxyribonucleic acid. DNA is found in almost all of the cells in the body.
A gene is that part of DNA which pertains to family traits.
How is DNA obtained? Cells from blood or other body materials are processed in a laboratory that
has special equipment that can extract DNA and identify genes.
How long is the DNA kept? Dr. Garg will keep your sample of DNA, cells or tissue in a research
laboratory at this medical center until it is all gone, or until he decides to discard the sample. If there
is a power failure in the laboratory, and your frozen sample thaws, the sample could become spoiled
and useless for future research. If that happens, the sample would be discarded.
If your sample remains stored beyond your lifetime, your sample will be used as described in this
document.
May other researchers use your DNA? With your permission, Dr. Garg may give some of your
DNA, cells or tissue to other medical scientists who are studying lipodystrophy, premature aging or
related syndromes. DNA given to other scientists will not be labeled with your name or any other
information that could be linked to you in any way.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
Who decides which research scientists may receive samples of your DNA? Dr. Garg asks your
permission to use your sample of DNA, cells or tissue as he chooses. The sample will be used only
for medical research and will not be sold.
Dr. Garg will decide which researchers at this medical center and at other medical centers may
receive samples of your DNA, cells or tissue. Your samples may be used in other research only if the
other research has been reviewed and approved by an Institutional Review Board (IRB).
Could your sample be used for other purposes? No one may use your sample or your DNA for
purposes other than research without your permission or without the permission of your legally
responsible representative and the approval of the IRB at this medical center.
Will the results of research tests be reported to you? Dr. Garg will use samples of your DNA,
cells or tissue only for research. The samples will not be used to plan your health care.
Will you be contacted in the future? You may be contacted later for information about your health.
Please keep in touch with Dr. Garg and maintain a current address and telephone number on file.
Please notify Dr. Garg if your legal name changes.
Dr. Garg or a member of his research team may invite you to participate in other research in the
future.
Dr. Garg may recommend that you discuss new information about lipodystrophy, premature aging or
a related syndrome with your personal physician.
Any new information which becomes available during your participation in the research and may
affect your willingness to continue in the research will be given to you promptly.
Will children be contacted in the future? It is your responsibility to inform a child that samples of
his or her DNA, cells or tissue may be kept in a research laboratory at this medical center or possibly
other medical centers. The child will not be asked to sign another consent form when he/she reaches
age 18.
What are some of the risks that could result from participation in this kind of research?
Stress: You could experience stress from participating in this kind of research. Knowing that
researchers have personal information about you may trouble you.
Personal, sensitive information: If you are not the parent of a child in your family, or if you are the
parent of a child in another family, that information could be learned from DNA tests. This kind of
information will not be reported to you or other family members without your permission.
What is a Certificate of Confidentiality? The Department of Health & Human Services issued a
Certificate of Confidentiality for this research. This Certificate enables [insert name of investigator]
and other researchers associated with this project to withhold information about your participation.
The protection afforded by this Certificate lasts forever. However, the Certificate will not provide
protection if you consent in writing to the release of information about your participation in the
research to anyone else.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
Why is a Certificate of Confidentiality needed? Sensitive information about your health and the
health of other members of your family may be collected and studied. The Certificate will help DR.
Garg avoid having to release identifying information about you which could expose you and your
family to unwanted financial, legal, emotional, and social consequences.
How does the Certificate of Confidentiality protect your privacy? All persons who are employed
by or associated with the University of Texas Southwestern Medical Center at Dallas (and its
contractors or cooperating agencies) and who have access to information about your participation in
this research may withhold your name and other identifying information from all persons not
connected with the conduct of that research.
This means that Dr. Garg does not have to identify you as a participant in this research in any
Federal, State, or local, civil, criminal, administrative, legislative, or other proceedings.
What are the limitations of the Certificate? This Certificate does not stop you or a member of your
family from identifying you as a participant in this research.
For example, if an insurance provider or employer learns about your participation in this research and
obtains your consent to receive research information, Dr. Garg may not use the Certificate of
Confidentiality to withhold this information.
It is important that you and your family actively protect your own privacy.
If Dr. Garg determines that you could be harmful to yourself or to others, he may report such
concerns to proper authorities for your safety or the safety of others. If the investigators suspect
child, elder or disabled person’s abuse, they will report such concerns to the proper authorities as
required by law.
A Certificate of Confidentiality does not represent an endorsement of this research project by the
Department of Health & Human Services or any other Federal government agency.
Could there be problems if you or someone else in the family releases information? If you or a
member of your family receives private information about you and does not maintain the privacy of
that information, there is no way to predict who will have access to that private information. There is
no way to predict the risks or damage which could result from unwanted release of that information.
How do you stop your participation in the research? If you prefer to stop participation in this
research, you may ask Dr. Garg to destroy any record of your participation in this research and to
destroy any sample with your name on it. You will not be asked for further information or samples.
Your identity will be removed from all research records. However, the resulting data from the
research will not be discarded. Copies of DNA and/or growing cells made from your samples will not
be destroyed.
Samples sent to other scientists cannot be identified and destroyed because your name was removed
before the samples were shipped to other medical centers.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
The University of Texas Southwestern Medical Center at Dallas
Children’s Medical Center, Parkland Health & Hospital System
Retina Foundation of the Southwest, Texas Scottish Rite Hospital for Children
Zale Lipshy University Hospital, St. Paul University Hospital
The University of Texas Southwestern Moncrief Cancer Center
Authorization for Use and Disclosure of
Health Information for Research Purposes
NAME OF RESEARCH PARTICIPANT: _______________________________________________
1. You agree to let UT Southwestern Medical Center, Parkland Hospital, The Clinical Translational
Research Center ( CTRC), share your health information with Dr. Abhimanyu Garg and his or her staff at
the University of Texas Southwestern Medical Center at Dallas (“Researchers”) for the purpose of the
following research study: Physical and Metabolic Abnormalities in Lipodystrophy, A study to understand
different types of fat variations, such as fat loss or fat redistribution and the underlying genetic basis. IRB
File # 1093-37500
2. You agree to let the Researchers use your health information for this Research Project. You also agree
to let the Researchers share your health information with others who may be working with the Researchers
on the Research Project (“Recipients”) as follows.

NIH ( National Institutes of Health ) The sponsor includes any people, entities, groups or companies
working for or with the sponsor or owned by the sponsor. The sponsor will receive written reports
about your participation in the research. The sponsor may look at your health information to assure
the quality of the information used in the research.

Rogers MRI, CTRC Core Lab, Mineral Metabolism Lab, Quest lab, Aston Radiology. These are other
research facilities that are working with UT Southwestern on the Research Project.

The UT Southwestern Institutional Review Board (IRB). This is a group of people who are responsible
for assuring that the rights of participants in research are respected. Members and staff of the IRB
at UT Southwestern may review the records of your participation in this research. A representative
of the IRB may contact you for information about your experience with this research. If you do not
want to answer their questions, you may refuse to do so.

Representatives of the Office of Human Research Protections (OHRP). The OHRP may oversee the
Research Project to confirm compliance with laws, regulations and ethical standards.
3. Whenever possible your health information will be kept confidential. Federal privacy laws may not apply
to some institutions outside of UT Southwestern. There is a risk that the Recipients could share your
information with others without your permission. UT Southwestern cannot guarantee the confidentiality of
your health information after it has been shared with the Recipients.
4. You agree to permit the Researchers to use and share your health information as listed below:
Medical history, physical exams, DEXA scans, MRI scans, MRS scans, blood tests, urine tests, pregnancy
tests, biopsies, HIV status, current and previous medications, questionnaires, and photographs and
DNA testing if applicable .
5. The Researchers may use your health information to create research data that does not identify you.
Research data that does not identify you may be used and shared by the Researchers (for example, in a
publication about the results of the Research Project); it may also be used and shared by the Researchers
and Recipients for other research purposes not related to the Research Project.
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
6. This authorization is voluntary. Your health care providers must continue to provide you with health
care services even if you choose not to sign this authorization. However, if you choose not to sign this
authorization, you cannot take part in this Research Project.
7. This Authorization has no expiration date.
8. If you change your mind and do not want us to collect or share your health information, you may cancel
this authorization at any time. If you decide to cancel this authorization, you will no longer be able to take
part in the Research Project. The Researchers may still use and share the health information that they have
already collected before you canceled the authorization. To cancel this authorization, you must make this
request in writing to:
Claudia Quittner
UT Southwestern Medical Center
5323 Harry Hines Blvd.
Dallas, Texas 75390-9052
Phone 214-648-9296
9. A copy of this authorization form will be provided to you.
Signature of Research Participant
Date
For Legal Representatives of Research Participants (if applicable):
Printed Name of Legal Representative:
Relationship to Research Participant: _________________________
I certify that I have the legal authority under applicable law to make this Authorization on behalf of the
Research
Participant
identified
above.
The
basis
for
this
legal
authority
is:
_______________________________________________________________________________________.
(e.g. parent, legal guardian, person with legal power of attorney, etc.)
Signature of Legal Representative
Date
Study ID: STU 082010-274 Date Approved: 10/11/2010 Expiration Date: 10/3/2011
THE UNIVERSITY OF TEXAS
SOUTHWESTERN MEDICAL CENTER
AT DALLAS
Ambulatory Services
Notice of Privacy Practices
Acknowledgement of Receipt Form
Pt. Name:______________________________________________
Address:_______________________________________________
______________________________________________________
City
State
Zip
MRN: _________________________________________________
DOB: _________________________________________________
SSN: _______________________________________SEX:______
DOS: _________________________________________________
40001234
Your signature below indicates that you have been offered a copy of UT Southwestern’s Notice of
Privacy Practices. If you have any questions about the Notice of Privacy Practices, please call
The UT Southwestern’s Privacy Officer at 214-648-2000.
I have been offered the Notice of Privacy Practices.
Patient Signature
Date
Print Patient Name
Date
Legal Guardian or Patient Representative Signature
Date
Print Legal Guardian or Patient Representative Name
Date
Relationship to Patient
Date
Please describe relationship to patient if other than self.
FOR OFFICE USE ONLY:
UT Southwestern will make a good faith effort to obtain a written acknowledgement of receipt of the
Notice provided to the individual. If the patient is unwilling and or unable to sign this acknowledgment,
UT Southwestern must document its good faith efforts to obtain such acknowledgement and record the
reason why the acknowledgement was not obtained.
Reason:
Notice mailed to patient Date:
Form # FMA/NPPARF-001 / 02.03
COMPLIANCE
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Staff Signature: