Consent Template: Combined HIPAA - The Children's Hospital of ...

Consent for Use of Data for Future Research
As part of the study, we will collect information about your growth and health. These
data will be given a unique code and will include no information that can identify you. A
Master List will be kept that links your data to you. This information will be kept in a
separate, password protected computer database at the Research Institute of the
Children’s Hospital of Philadelphia. Only the study doctors and those working with them
on this study will be able to see information that can identify you.
If you leave the study, you can ask to have the data collected about you removed or your
samples destroyed. You can also ask us to remove information that identifies you from
the data.
We may wish to use your stored information in a future study. Please let us know if you
will let us do that by putting your initials next to one of the following choices:
_____ (initials) My data may be used for this study only.
_____ (initials) Provided that my identity stays private, my data may be used for other
future research studies.
Version 3
CHOP IRB#: IRB 09-007306
Approval Date: 11/8/2010
Expiration Date: 11/7/2011 Page 6 of 8