>>>>>>Form to be on Trust headed paper<<<<<
Hospital:
Patient:
(Name, DOB and unique identifier eg Hospital Number)
ASSENT FORM for Child/Young Adult aged 11-16 years
(To be completed once parental/guardian has consented for children <16 years)
Title of Project: The United Kingdom Thrombotic Thrombocytopenic Purpura Registry (UK TTP
Regsitry)
Chief Investigator: Dr Marie Scully, 60 Whitfield Street, London W1T 4EU
Please initial
in box if you
agree

I have read and understood the information sheet (version 2.0, dated 6th
October 2010)

I have had time to ask questions and have had these answered

I know that I can stop doing the study at any time without my treatment
being affected in any way.

I know that my medical notes will be reviewed by the researcher(s). I give
my permission for them to do this.

I agree to give an extra blood sample for DNA analysis. I agree to the
storage of my DNA and serum samples at the Haemostasis Research Unit,
UCL for use in future TTP research.

I agree to be in this study.
____________________________
Name of patient in full (please print)
__________________
Date
___________________
Patient’s signature
____________________________
Name of researcher
________________
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 (11-16 years), Version 2.0, 6th October 2010
Page 1 of 1