Protocol Title:

Principal Investigator:

AUTHORIZATION TO SHARE PERSONAL HEALTH INFORMATION IN RESEARCH

The word �you� means both the person who takes part in the research, and the person who gives permission to be in the research. This form and the attached research consent form need to be kept together.

We are asking you to take part in the research described in the attached consent form. To do this research, we need to collect health information that identifies you. We may collect the results of tests, questionnaires, and interviews. We may also collect information from your medical record. We will only collect information that is needed for the research. This information is described in the attached consent form. For you to be in this research, we need your permission to collect and share this information.

We will share your health information with people at the hospital who help with the research. We may share your information with other researchers outside of the hospital. We may also share your information with people outside of the hospital who are in charge of the research, pay for or work with us on the research. Some of these people make sure we do the research properly. The �confidentiality� section of the consent form says who these people are. Some of these people may share your health information with someone else. If they do, the same laws that the hospital must obey may not protect your information.

If you sign this form, we will collect your health information until the end of the research. We may collect some information from your medical records even after your direct participation in the research project ends. We will keep all the information forever, in case we need to look at it again. We will protect the information and keep it confidential.

Your information may also be useful for other studies. We can only use your information again if a special committee in the hospital gives us permission. This committee may ask us to talk to you again before doing the research. But the committee may also let us do the research without talking to you again if we keep your health information private.

If you sign this form, you are giving us permission to collect, use, and share your health information. You do not need to sign this form. If you decide not to sign this form, you cannot be in the research study. You need to sign this form and the attached consent form if you want to be in the research study. We cannot do the research if we cannot collect, use, and share your health information.

If you change your mind later and do not want us to collect, use, or share your health information, you need to send a letter to the researcher listed on the attached consent form. The letter needs to say that you have changed your mind and do not want this authorization form to be good anymore. Until we get such a letter, we will continue to do the things you said we could in this form. You may also need to leave the research study if we cannot collect any more health information. We may still use the information we have already collected. We need to know what happens to everyone who starts a research study, not just those people who stay in it.

Any questions? Please ask the researcher. You can also call (000) 555-5555 with questions about the research use of your health information. The researcher will give you a signed copy of this form.

SIGNATURE, DATE, AND IDENTITY OF PERSON SIGNING

The health information about ___________________________________ can be collected and used by the researchers and staff for the research study described in this form and the attached consent form.

Signature: __________________________________________ Date:_____________________

Print name: __________________________________________ Relation: __________________

Note: The size and style of the type have been altered for this reproduction. The actual size and typeface should be 12 pt. Times Roman

Source: Developed as a proposed draft by Robert M. Nelson, MD, PhD, Associate Professor of Anesthesia and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania.