MRC Cognitive Function and Ageing Study II
Administrative Centre
Department of Public Health and Primary Care
Institute of Public Health
University of Cambridge
Forvie Site
Robinson Way
Cambridge CB2 2SR
Telephone: 01223 330312
Fax: 01223 330330
CAMBRIDGESHIRE PROJECT FOR LATER LIFE II
(Letterhead amended for each centre)
BRAIN DONATION
DECLARATION OF INTENT FOR DONOR
PROJECT NO……………………………
NAME OF DONOR…………………………………………………..
Please Initial
I have read the attached information sheet (Version 1.2 09/07/2007)
and have been given a copy to keep.
YES
□ □
□ □
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YES
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YES
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YES
I have been given an opportunity to ask questions about brain
YES
donation
I wish to make a gift of my brain to medical research.
I am aware that my gift will be placed under the custodianship of
NHS Brain Banks supporting the Cambridgeshire Project for Later
Life II Study.
Research involving genetic (DNA) study of tissues and cells may
lead to the discovery of genes that either predispose to, or protect
against, disease. I understand that using the sample I give, may
include genetic (DNA) research aimed at understanding the genetic
influences on diseases related to ageing such as Alzheimer's, but
that the result of these investigations are unlikely to have any
implications for me personally
NO
NO
NO
NO
NO
A collaborating centre in the Medical Research Council Cognitive Function and Ageing Study II
Brain Donation consent form
Version 1.2 09/07/2007
The gift of brain donation is intended primarily to support the
research project entitled "The Cambridgeshire Project for Later Life
II” I agree that my gift may be used in the future for related YES
research projects as approved by a Research Ethics Committee.
□ □
NO
Development of new drug therapies and diagnostic tests to the point
where they can be made sufficiently widely available to benefit
human health, can sometimes only be achieved with the
involvement of the commercial sector. I agree that my gift of tissue YES
may be used to help the commercial sector achieve these aims?
□ □
I understand that neither my family nor I will benefit financially if
this research leads to the development of a new treatment or
medical test.
YES
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YES
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I know how to contact the research team if I need to, and how to get
YES
Information about the results of the research.
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International co-operation enables us to work with approved
collaborators worldwide to advance medical research. I agree that
you may send tissue abroad from my gift to approved collaborators
outside the UK?
I confirm that, I wish to donate my brain and related fluids to NHS
Brain Banks supporting the Cambridgeshire Project for Later Life II YES
for use in medical research as indicated.
NO
NO
NO
NO
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NO
Signature……………………………………………………………
Name in Capitals……………………………………Date………..………………
Witness Signature…………………………………………………..
Name in Capitals……………………………………Date……………………….
A collaborating centre in the Medical Research Council Cognitive Function and Ageing Study II
Brain Donation consent form
Version 1.2 09/07/2007
CONTACT DETAILS
PROJECT NUMBER…………………………………………………
NAME OF DONOR…………………………………………………...
DATE OF BIRTH……………………………………………………..
ADDRESS……………………………………………………………..
………………………………………………………………………….
………………………………………………………………………….
TEL NO………………………………………………………………..
NAME OF NEXT OF KIN…………………………………………...
ADDRESS OF NEXT OF KIN……………………………………….
………………………………………………………………………….
………………………………………………………………………….
RELATIONSHIP TO DONOR……...……………………………….
TEL . NO………………………………………………………………
NAME OF DOCTOR…………………………………………………
SURGERY……………………………………………………………..
………………………………………………………………………….
TEL . NO………………………………………………………………
A collaborating centre in the Medical Research Council Cognitive Function and Ageing Study II
Brain Donation consent form
Version 1.2 09/07/2007