Modified Consent Form CM4a

CM4a –Adult Consent for Biological Samples Signature Form

Population Assessment of Tobacco and Health (PATH) Study

Consent for Biological Samples Signature Form

I have read the Biological Urine Samples Consent Pamphlet or it has been read to me. My questions about the PATH Study have been answered and I understand the following.

• What is involved if I decide to give samples.

• I decide whether to give samples. I can decide not to give any sample and still be part of the PATH Study.

• I decide whether my samples are used in genetic research. I can decide not to have my samples used in this research and still be part of the PATH Study.

• I can tell the PATH Study to stop storing and using my samples at any time. Also, I can tell the PATH Study to destroy my samples.

• The PATH Study will store my samples in a secure facility and make sure only qualified researchers who have agreed to keep my information private have access to them.

• The PATH Study will use my samples for a variety of tests.

• I will not get results back from the tests done on my samples.

• What the risks and benefits are if I give samples.

• I can ask more questions at any time.

• I’ll get a copy of this consent form.

I agree to give:

A sample of cheek cells.  Yes  No

A urine sample.  Yes  No

A blood sample.  Yes  No

I agree to the use of my samples for genetic research.  Yes  No

__________________________________________ _______ / ______ /______

Signature of Participant Month Day Year

__________________________________________ _______________________

Printed Name of Participant ID # of Interviewer

__________________________________________ _______ / ______ /______

Signature of Person Obtaining Consent Month Day Year

THANK YOU

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