GA4GH Model Data Sharing Consent Form Study : ST-123456 / Consent : C-U5432
Principal Investigator:
Andrea Ang
Organization Name:
Notional Institute of Technology
Funded by:
National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892
Contact Person:
Solomon Shirley, 332 Main Street, Waltham, MA 02452
Study: The Aphasia Inquiry will include some or all of the following:
Data collected during the project;
Some data from your medical file or other personal and health information;
Your self-reported health related data; and
Data from your stored tissues.
Time: Your data will be kept for a period of seven years. Compensation: You will not be reimbursed or paid. Some of the research done with the information stored in the databases may one day lead to the development of software, tests, drugs, or other commercial products. If this happens, you will not receive any of the profits. Withdrawal: You can withdraw by telephone to 1.617.671.7617 or by email to solomon.shirley@amail.com. Signature:Your email/address: roberta@robinsonandson.com