University of California, San Francisco

(Downloaded 23 June 2015 from


What is the purpose of this consent? The doctors in the ________ Clinic [or Division or other appropriate name for site] at UCSF are doing research that is designed to lead to better treatments for the types of medical problems experienced by the people who come to this clinic. They want to know if you wish to learn more about their research studies or if you may wish to participate in any of the studies that may be appropriate for you. By signing this form, you will allow qualified professional people on the staff on this clinic to contact you in the future to ask if you want to participate in any studies. You have no obligation to actually participate in any study.

What happens if I sign this form? If you sign this form, you are giving consent for information to be taken from your UCSF medical records. This list includes information about your diagnosis, your name, medical record number, date of birth, diagnosis and contact information. This information will be kept indefinitely, unless you withdraw your permission. If a study on your condition needs subjects, you may be contacted to ask if you want to participate. You do not have to participate. You may withdraw permission to be contacted at any time by contacting the clinic.

What happens if I don’t sign this form? Declining to participate will have no influence on your present or future status as a patient in this clinic. You will receive the same care as any other patient seen in this clinic. There will be no penalty or loss of benefits to which you are otherwise entitled. Your clinic records will indicate that you do not want to be asked about future research by or through anyone but your treating physician.

Are there any risks to my signing this form? Participation in research may involve some loss of privacy. However, your records will be handled as confidentially as possible. Access will be limited to the data manager and the doctor organizing the study and will require a password. No information will be used for research without additional permission. Your contact information will not be shared with anyone outside this clinic.


Are there any financial considerations? There will be no cost or payment to you if you sign this form.

What do I do if I have questions, now or later? You can talk with the study researcher about any questions, concerns or complaints you have about this study. Contact the study researcher(s) __________________ [name(s)] at __________________ [telephone number(s)].

If you wish to ask questions about the study or your rights as a research participant to someone other than the researchers or if you wish to voice any problems or concerns you may have about the study, please call the Office of the Committee on Human Research at 415-476-1814. [If there are additional informational sources related to the study (e.g., patient representatives or individuals at other study sites as appropriate), list here with contact information.]

What do I do to consent? If you agree to be contacted in the future, please indicate your preferred contact method and sign below.

Preferred contact method: (Please fill in one method)


Phone: _________________________________________ †        

Mail: __________________________________________ †        

Email address: ___________________________________

_____________________________________ _________________

Signature                                                  Date

_____________________________________ _________________

Signature of Person Obtaining             Consent Date

Version Date: Feb 08