1. Nature and objectives of the study

[Describe the study purpose, in addition to the current and future scope of research.]

The [identify biobank/title of study] is a resource that contains biological materials, such as DNA samples, in addition to health/lifestyle information and personal information (data) on a large number of people over time. It has been set up so that it can be used in the future as a resource for researchers undertaking a wide range of medical research.

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This [biobank/study] has two main aims. The first aim is to gain a better understanding of the interactions between genes, the environment, and our lifestyle that influence our health or cause diseases. The second aim is to use this understanding to develop new drugs, genetic tests, and treatments, and to create public health strategies that will benefit everyone.

Your participation in this project involves you giving broad consent. This means that you allow your personal information and samples to be used for a variety of future medical research approved by an ethics committee, but which cannot be specified at the present time.

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2. Prospective participants

[Outline the total number of expected participants, and explain why the individual was selected to participate.]

The [biobank/study] involves the participation of [number] people between [age] and [age] years of age from [region].

You have been chosen from [identify database, registry, etc.] to be invited to participate.

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However, please note that you should not participate if [enumerate exclusion criteria].

3. Researchers and institutions conducting the study

[This section should also disclose any conflicts of interest.]

The [biobank/study] is a research effort led by [identify institution(s)]. This institution is responsible for the practical aspects, such as data collection and secure storage of samples and data. It will be the point of contact for you, and for the researchers who use the biobank. The person who has overall responsibility for the management of the biobank is [name of executive director]. If you need to contact the biobank for any reason, please telephone [name] at [telephone number], email [email address], or write to [mailing address].

The [biobank/study] is supported by [identify institution(s)] and is funded by [name(s) of sponsor(s)/government agency]. The [name of study] has received approval from [name of research ethics committee].

4. What does participation involve?

[Outline study procedures; what participants are expected to do throughout the course of the study; include types of information being gathered (samples and data); amount of information being gathered; tests to be performed (manner of acquiring samples); questionnaires; length of time; location, etc.]

If you choose to participate, you will be asked to:

1.

Undergo a physical assessment, which involves you:

•

attending an appointment at [insert location], which will last approximately [insert duration of appointment];

•

providing a [insert sample type (e.g. blood, urine, saliva)] sample of [insert amount/measures of samples taken], which the biobank will store;

•

answering a questionnaire on [insert topics (e.g. your health and lifestyle, family, and medical history)] that will take approximately [insert length of time]; and

•

allowing our staff members to perform basic measurements, including [insert measurement types (e.g. measuring your weight, height, and blood pressure)].

The physical assessment will be conducted by [qualified health professionals (e.g. nurses, physicians)]. In total, it should take approximately [insert duration of entire assessment].

2.

Allow your samples and data to be stored and used in coded form by researchers for many years [if applicable, specify length of time].

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5. Study risks

[List possible disadvantages or risks (e.g. discomfort, malaise, stress, transportation costs, time)]

Your participation entails few risks. The physical assessment involves little risk. The taking of a blood sample for DNA analysis may cause some bleeding, bruising, dizziness, and/or discomfort. You should be aware that certain physical measurements that will be taken [e.g. your weight] and/or some of the questions you will be asked in the questionnaire may be personal in nature. The storage of your samples and the extraction of DNA involve minimal risk, because rigorous security measures are in place (as described below) and all samples will be kept in a high-security facility.

Unless required by law or a court order, access to this information will not be offered to third parties such as employers, insurance companies, or family members. Only authorized staff members will have access to your information. For requests for access by researchers, they will not be given any information that would allow them to identify you. The utmost care will be taken to ensure the confidentiality of all data.

6. Potential study benefits

You will not directly benefit by taking part in this study, because the most important health benefits will be realized many years from now. Rather, your participation will contribute to the advancement of scientific knowledge and help future generations, because your participation is expected to improve our understanding of genetic and non-genetic factors that affect the health of the population.

However, any immediate, life-threatening condition will be reported to you immediately so that you can obtain emergency care.

7. Privacy and confidentiality

[Specify who will have access to the participants’ personal information and the types of information.]

The information in your file could include your past and present medical history, in addition to information about your life and test results from examinations and procedures done during this study. Your file could also contain information such as your name, sex, date of birth, and ethnic origin.

All information collected about you will remain confidential. No one will have access to your directly identifying information, that is information that identifies you through specific identifiers such as your name, your social insurance number, and your personal health number.

To protect your privacy, your information will be coded. “Coded” means that your information has been stripped of any direct or indirect identifiers, which are replaced by a numerical code. A list that links the coded information with your identity will be kept secure, to allow for your re-identification in certain circumstances. Your unique code will enable us to link the information from different datasets to you, but at the same time, will enable us to keep your identity confidential when we give your data to other researchers to use.

While study information could be printed in journals or shared with other people at scientific meetings or for teaching purposes, it will not be possible to identify you. Your identity will be kept confidential. All data will be presented as group data, rather than individual data.

Also, specific rules regulate access to your data and samples by researchers. Researchers will not have access to any of your personal information.

8. Access to your data and samples

Only approved research studies can gain access to your coded data and samples, in order to protect your privacy. An approved researcher can be from [outline the approved users as per access policy (e.g. academia, a charitable organization, a private company, or a public institution)]. All projects must be approved by the [identify the access committee], who will essentially review whether the proposed study has received prior scientific and ethical approval by the relevant committees, and that the study fits within the purpose of the biobank and meets other general requirements.

Researchers have to sign agreements that control their access to data and samples, and they are not permitted to disclose or transfer data or samples to anyone else or to use them for purposes other than those agreed to. Researchers must also agree that they will not attempt to re-identify you from your data and samples and should immediately report any re-identification of participants to the biobank.

We also expect to receive access requests from overseas researchers and international collaborators. These researchers must follow the same procedures as all other researchers. All access is subject to the strictest scientific and ethical scrutiny, as described above.

When transferred samples are no longer needed for the purpose for which they were given to researchers, researchers must [return them to the biobank or destroy them]. Researchers must also return their research results to the biobank, so that those results are available for other researchers to use in the future. This facilitates future research and enriches the database of the [name of biobank].

9. Storage of your data and samples

[Specify where the data and samples will be stored (location) and how long they will be stored.]

Your data and samples will be stored in a database at [name of institution/hospital and location]. This is a secure facility, meeting international security and safety standards for laboratories. Also, in order to keep your information confidential, numerous safeguards are in place. In particular, we will:

•

remove personal identifiers such as your name or date of birth from your samples and records;

•

assign codes to your samples and records;

•

keep your personal details separate from your data and samples;

•

use stringent security measures to prevent unauthorized use, including strict access controls, computer security and data encryption techniques, confidentiality agreements, and staff training;

•

hold information in secure databases, which can be accessed only by the authorized staff members and by approved researchers, who will only have access to coded information; and

•

have a decoding step that will allow us to re-link your personal details with your samples and information, should you want to withdraw from the study or in order to make sure that the database records are correct.

Your samples and data will be kept for a period of [identify period of conservation (e.g. number of years)]. After this period, your samples and data will be [destroyed or transferred], unless an ethics committee decides otherwise.

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10. Withdrawing from the study

[Indicate treatment (planned use and storage procedures) of already collected data/samples.]

You may choose whether or not you wish to take part in this study. If you choose to take part now, you can change your mind later and withdraw, meaning stop participating at any time and for any reason.

You can withdraw by [indicate ways for participant to signal their withdrawal (e.g. by telephone, by email, by mail, and whom to contact)]. You will receive a letter confirming your withdrawal.

If you withdraw, your identifiable samples and the data derived from your samples and other personal information will be destroyed if possible. Data that are already being used for research cannot be destroyed or removed.

The code that enables us to re-link your samples and personal information will be deleted so that no further information about you will be collected. Only your signed consent form and a copy of the letter confirming your withdrawal will be kept as a record of your wishes. Such a withdrawal will prevent information about you from contributing to further research and analyses.

11. Return of research results

[Outline the biobank’s policy as to returning results, including the results from the laboratory assessment and physical assessment, general research results, individual research results, and incidental findings. If the biobank’s policy is to return individual results, indicate who has the obligation of returning these results and for how long.]

(a) Results from laboratory assessment and initial physical assessment

You can choose to immediately receive the results of your physical assessment, such as [specify results that can be returned], from your [type of assessment (e.g. BMI, ECG, blood pressure)]. These results will be provided with the appropriate explanations (e.g. your measurements alongside “standard measures”). You can decide whether you want these measurements sent to you or not.* If, during the physical assessment, we find something that we feel should be explored further, we will advise you to see your personal doctor, because the assessment is not a clinical check-up.

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(c) Individual research results and incidental findings

Individual research results are results discovered during the course of research that concern you and have potential health or reproductive consequences.

Incidental findings are unforeseen findings about you that have potential health or reproductive consequences. Although they were discovered during the course of research, they are outside of the study objectives.

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12. Re-contact

With your permission, we may re-contact you to invite you to update your questionnaire or to provide additional samples or to be involved in new research projects by other researchers that could require additional physical assessments, tests, and questions.

13. Compensation

[Include travel expenses and the procedure for reimbursement.]

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14. Possible commercialization

[Explain the potential uses of data and samples, including the development of intellectual property and commercial uses.]

[Identify biobank or specific committee] has been set up as the [guardian/owner/custodian] of the database and sample collection. The use of your data and samples might someday lead to the commercialization of a medical or genetic test or product. This may be done by a university or hospital, a commercial company, or both working in partnership. This means that researchers, including, potentially, commercial companies, may benefit financially. You will not derive any personal financial advantage from this commercialization.

15. Closure of the biobank

[Explain what will happen upon the closure of the biobank, whether the closure is scheduled or unplanned.]

If the [name of biobank] were to close for whatever reason, [see Alternative clauses].

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16. Your questions or concerns

If you have any questions or concerns, please contact [insert name of person] free of charge at [insert telephone number] or by mail/email at [insert mailing address and/or email address].

If you wish to make a complaint about any aspect of this study at any time, please contact [insert name of person] free of charge at [insert telephone number] or by mail/email at [insert mailing address and/or email address]. We take all comments seriously and will get back to you as soon as possible.

Thank you for considering taking part in this study!

[Insert logo and letterhead of biobank]

PARTICIPANT CONSENT FORM

[Name of biobank/Title of study]

Name of biobank: [insert name of biobank]

Investigator(s): [insert name(s) of investigator(s)]

Sponsor(s): [insert name(s) of sponsor(s)]

The goal of the [biobank/study] is [provide a brief summary of goal].

BY SIGNING THIS CONSENT FORM, I AGREE TO PARTICIPATE IN THE [BIOBANK/STUDY] AND DECLARE THAT:

• Ø I have read and understood the information pamphlet [version/date]. I have had the opportunity to consider the information it contains and to ask all the questions I had. I have obtained satisfactory answers to my questions.
• Ø The risks and benefits of my participation have been explained to me.
• Ø I understand that my participation is voluntary. I am free to withdraw at any time, without giving any reason. This can be done by contacting [insert name] at [insert telephone number, email address, and/or mailing address]. I will receive a letter confirming my withdrawal.
• Ø I understand that I will not receive any personal financial benefit from any possible commercialization of a test or product developed by using my data and samples.
• Ø I understand that my participation does not entail any direct personal benefit. However, any immediate, life-threatening condition will be reported to me immediately so that I can obtain emergency care.
• Ø I understand that upon closure of the biobank, my data and samples will be [specify policy for closure: archived, destroyed, or transferred to another biobank].
• Ø I understand that unless access is required by law, only approved researchers will have access to my coded data and samples. Access is subject to ethics approval and oversight.
• Ø I understand that general research results, meaning aggregate results, will be made available to participants, researchers, and other people who might be interested through [specify format (e.g. website, newsletter)] in order to make data more readily available and encourage medical advances.

I AGREE TO:

• Ø Undergo a physical assessment, including:

  •

  attending an appointment at [insert location], which will last approximately [insert duration of appointment];

  •

  providing a [insert sample type (e.g. blood, urine, saliva)] sample of [insert amount/measures of samples taken], which the biobank will store;

  •

  answering a questionnaire about [insert topics (e.g. my health and lifestyle, family, and medical history)]; and

  •

  allowing staff members to perform basic clinical measurements, including [insert measurement types (e.g. measuring my weight, height, and blood pressure)].

• Ø Allow my coded data and samples of [insert sample type (e.g. blood, cells, DNA, urine, saliva)] to be used for various research purposes approved by the relevant research ethics committee.

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• Ø Have my data and samples stored at [specify storage location] for [specify period of conservation]. All data and samples will be kept in a secure facility overseen by [insert name of individual or committee].
• Ø Allow my data contained in administrative health records to be examined now and in the future. My records and samples will continue to be accessed even if I become unable to make decisions for myself or if I die.

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RETURN OF RESULTS

a) Results from laboratory assessment and initial physical assessment

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b) Individual research results and incidental findings

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RE-CONTACT

• Ø I agree to be re-contacted by [identify biobank/study] to update my data (questionnaires or physical measures) or to provide additional data/samples.
  • YES □ NO □
• Ø I agree to be re-contacted by [identify biobank/study] to participate in new research projects conducted by other researchers that could require additional physical assessments, tests, questions or samples.
  • YES □ NO □

CONFIRMATION BY INVESTIGATOR OR HIS/HER DESIGNEE

I described the [identify biobank/study], including the conditions of participation, to the participant. I explained the contents of the information pamphlet and consent form to the participant. Any questions were answered. I explained that participation was voluntary.

Investigator/Designee name __________________ Signed _________________ Date _______

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PARTICIPANT INFORMATION

I agree to participate IN [BIOBANK/STUDY] and will receive a copy of this consent form after I sign it.

Name: __________________________________________________________________

Signed: __________________________________________ Date: ______________

THANK YOU FOR PARTICIPATING! FOR MORE INFORMATION, PLEASE CONTACT: [insert website, name of person to contact, telephone number, email address].

To file a complaint regarding your participation, please contact: [insert name of person to contact, telephone number, email address, and mailing address].