Research Consent Form

Dana-Farber/ Harvard Cancer Center

BIDMC/BWH/CH/DFCI/MGH/DFPCC Network Affiliates

OHRS 07.17.15

WITHDRAWAL OF CONSENT TO CONTINUE IN RESEARCH

A. INTRODUCTION
You are currently taking part in a research study. Study participation is voluntary
and you may decide to stop taking part now or at any time. If you decide to stop
participating in this research study, we encourage you to talk to the research
doctor and your regular doctor first.
Information about the study you are participating in, including the study number,
study title and name of the doctor who is overseeing the study (Principal
Investigator) is listed below:
Study
Number

Study Title

Principal
Investigator Name

B. DOCUMENTATION OF WITHDRAWAL OF CONSENT TO CONTINUE IN RESEARCH

Using this form, we are asking you to document your decision to withdraw from
this research study or to specify any components of the study you agree to
continue to participate in.
WITHDRAWAL OF CONSENT TO CONTINUE ON STUDY:

Please initial your choice below:

_____ I withdraw my consent to continue the study treatment. I agree to
continue as a study participant for follow-up visits and allow tests to be
completed that will continue to be used for research purposes.
_____ I withdraw my consent to continue the study treatment and I will not allow
more tests to be completed for research purposes. However (select as
applicable):
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Research Consent Form

Dana-Farber/ Harvard Cancer Center
BIDMC/BWH/CH/DFCI/MGH/DFPCC Network Affiliates

OHRS 07.17.15

_____ I agree to continue as a study participant by allowing information

collected from my medical records to be used for research purposes.
_____ I agree to continue as a study participant by allowing the study
team to contact my primary care physician for research- related
information.
_____ I agree to continue as a study participant by allowing the study
team to contact my family/caregiver for researchrelated information.
_____ I withdraw my consent to participate in any component of this research
study. I do not want any further medical information to be used for this research.
Information that has already been obtained will remain as part of the research
record, but no additional information will be added to the research record.
______ I withdraw my consent to continue to participate in research activities
such as banking, questionnaires andinterviews,Information that has already been
obtained will remain as part of the research, but no additional information can be
added to the research record.
Not Applicable No study intervention was involved.
Please note: If you are participating in a Food and Drug Administration (FDA)
regulated research study and you decide to stop participating in the study, the
FDA requires that any information collected up to the point of your withdrawal
cannot be removed from the study.
BIOLOGICAL SPECIMEN WITHDRAWAL OF CONSENT:

Please initial your choice below:

_____ Tissue and blood samples collected as part of the study may continue to
be stored for future research purposes.
_____ Tissue and blood samples collected as part of the study may not be
stored for future research purposes and I request that they be destroyed at the
facility where they are presently being stored. I understand that samples that
have already been used cannot be withdrawn.
Not Applicable No specimens have been collected.
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Research Consent Form

Dana-Farber/ Harvard Cancer Center
BIDMC/BWH/CH/DFCI/MGH/DFPCC Network Affiliates

OHRS 07.17.15

C. SIGNATURE
Participant Signature

Date

Participant Printed Name

___________________

Legally Authorized Representative

Legally Authorized Representative Not Applicable

Date ______________

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