Version 1.3; 18/05/2012
Consent Form
Genomic and expression profiling of brain tumors
Project ref 08/0077
Please initial box
I confirm that I have read and understood the information sheet dated May 2012
(version 1.6) for the above study and have had the opportunity to ask questions.
I confirm that I have had sufficient time to consider whether or not want to be included
in the study
I understand that only tissue appropriate for the treatment of my condition or for
establishing a diagnosis will be removed during surgery. I give my permission that tissue
which is surplus to requirements for diagnostic tests and that would normally be
disposed of may be used for research purposes.
Please
I understand that future research using my sample I give may include
contact
genetic research aimed at understanding genetic influences on diseases,
me
however the results of these investigations are unlikely to have any
implications for me personally. If they do, I wish / do not wish to be
contacted (please tick appropriate box).


Please
DO NOT
contact me


I understand that in agreeing to this use of tissue I am donating it indefinitely to the
NHNN/IoN. The NHNN/IoN will be responsible for its storage for its use in future
research projects and its eventual disposal.

I give my permission that, with the approval of my consultant, clinical data relevant to
the approved project may be extracted from my case notes and given the research
team for analysis. This data will be anonymised prior to its release

I understand that I will not benefit financially from the donation of the tissue
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
I agree to take part in this study



________________________
Name of Patient
(Patient/Guardian
delete as appropriate)
___________________
Date
_____________________
Signed
________________________
Name of Person
taking consent
___________________
Date
_____________________
Signed
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Version 1.3; 18/05/2012
Further information and contact details
For general information about research you may find the following websites helpful:
- http://www.nres.npsa.nhs.uk/
- http://www.brt.org.uk/
For specific information about this study or advice as to whether to participate please
contact:
- Professor Sebastian Brandner (Neuropathology)
Tel 020 3448 4435
- Mr Neil Kitchen (Neurosurgery)
Tel 020 7829 8714
Comments or concerns during the study
If you have any comments or concerns you may discuss these with the investigator. If
you wish to go further and complain about any aspect of the way you have been
approached or treated during the course of the study, you should write or get in touch
with the Complaints Manager, UCL hospitals. Please quote the UCLH project number at
the top this consent form
One signed original to be kept on file by the researcher
One copy to be given to patient (with a copy of the Patient Information)
One copy to be kept in the hospital notes
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Version 1.3; 18/05/2012
THE DATA AND PROTECTION ACT 1998
Data collection and medical research
In accordance to the requirements of the Data Protection Act 1998 we wish to inform you that we hold
information relating to your treatment at this hospital on a confidential secure database for the
purposes of providing health care and undertaking medical research and statistical analysis.
You have the right to request that information stored about you is removed from our databases. Please
let us know if this is the case by ticking the box below.

I, …………………………………….. date: ……………… do/do not * consent to having my personal data
stored on Institute of Neurology database.
* delete as appropriate
.
Signed:
………………………………….
Witness: …………………………………..
Date:
Print Name: ………………………….
Print Name: …………………………
…………………………………..
Investigator’s Statement:
I have explained the nature, demands and foreseeable risks of the above research to the subject:
Name: ………………………………………………………..
Signature:
…………………………………………………. Date: …………….
IMPORTANT:
One signed original to be kept on file by the researcher
One copy to be given to patient (with a copy of the Patient Information)
One copy to be kept in the hospital notes
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