>>>>>>Form to be on Trust headed paper<<<<<
Hospital:
Patient:
(Name, DOB and unique identifier eg Hospital Number)
ASSENT FORM for Child aged 6-10years
(To be completed once parental/guardian has consented for children <16 years)
Title of Project: The United Kingdom Thrombotic Thrombocytopenic Purpura Registry (UK TTP
Registry)
Chief Investigator: Dr Marie Scully, 60 Whitfield Street, London W1T 4EU
Tick the boxes if you agree
 I have read and understand the information about the study.
 I have asked all the questions about the study that I want to.
 My questions have been answered.
 I was told everything I want to know about what I have to do to
be in the study.
 I know I can stop being in the study whenever I want, for any
reason and I will still be looked after the same.
 I agree to give one extra blood sample for the study.
 I agree to be in this study.
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___________________________________________________
My Name
____________________________
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__________________________
Researchers Name
Date
Researcher’s signature
When completed 1 for patient; 1 (original) for researcher; 1 to be kept with hospital notes
UK TTP Registry: Assent for Child (6-10 years), Version 1.0, 3rdAugust 2010
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