/Docs/G/GA4GH/Demo/Roberta_Robinson_US_Summary
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(Summary = (Doc.Top = (Doc.Ti = GA4GH Model Data Sharing Consent Form)

(GUIDs.cl = Study : (Study.GUID = ST-123456)
/ Consent : (Consent.GUID = C-U5432)
)

(Study.Inv1.Role = Principal Investigator) (: = :)		(Study.Inv1.Name.Full = (Study.Inv1.Name.FL = (Study.Inv1.Name.First = Andrea) (Study.Inv1.Name.Last = Ang) ) )
(Study.Org.Role = Organization Name) (: = :)		(Study.Org.Name.Full = Notional Institute of Technology)
(Study.Funder.Role = Funded by) (: = :)		(Study.Funder.List.Name = (Study.Funder.N,A = (Study.Funder.Name.Full = National Institutes of Health) , (Study.Funder.Adr.1,2 = (Study.Funder.Adr.1 = (Study.Funder.Adr.Street.# = 9000) (Study.Funder.Adr.Street.Name = Rockville Pike) ) , (Study.Funder.Adr.2 = (Study.Funder.Adr.City = Bethesda) , (Study.Funder.Adr.ST = MD) (Study.Funder.Adr.Zip = 20892) ) ) ) )
(Study.Contact.Role = Contact Person) (: = :)		(Study.Contact.N,A = (Study.Contact.Name.Full = (Study.Contact.Name.FL = (Study.Contact.Name.First = Solomon) (Study.Contact.Name.Last = Shirley) ) ) , (Study.Contact.Adr.1,2 = (Study.Contact.Adr.1 = (Study.Contact.Adr.Street.# = 332) (Study.Contact.Adr.Street.Name = Main Street) ) , (Study.Contact.Adr.2 = (Study.Contact.Adr.City = Waltham) , (Study.Contact.Adr.ST = MA) (Study.Contact.Adr.Zip = 02452) ) ) )

)

Study: (1.2.sec = The (m- = )
(Study.Name.Full = Aphasia Inquiry)
(-m = )
will include some or all of the following: (1.2.List =

1. (1.2.1.sec = Data collected during the project)
   (; = ;)
   
2. (1.2.2.sec = Some data from your medical file or other personal and health information)
   (; = ;)
   
3. (1.2.3.sec = Your self-reported health related data)
   (; = ;)
   (and = and)
   
4. (1.2.4.sec = Data from your stored tissues)
   .

)
)

Time: (4.4.sec = Your data will be kept for a period of (m- = )
(Study.PersonalData.Retained.Duration = seven years)
(-m = )
.)

Compensation: (5.1.sec = (5.1.N.sec = You will not be reimbursed or paid. (5.1.2.Sen = 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: (9.2.1.Sen = (9.2.1.PhoneEmail = You can withdraw by telephone to (m- = )
(Study.Contact.Phone = 1.617.671.7617)
(-m = )
or by email to (m- = )
(Study.Contact.Email = solomon.shirley@amail.com)
(-m = )
. )
)

Signature:(Sign.8 = Your email/address: (m- = )
(Donor.Email = roberta@robinsonandson.com)
(-m = )


Signature: (m- = )
(Donor.xSignature = xROBERTA ROBINSON)
(-m = )


Date (m- = )
(Donor.Sign.YMD = November 7, 2014)
(-m = )


Researcher Signature (m- = )
(Clinician.xSignature = xALISON ANDREWS)
(-m = )


Date (m- = )
(Clinician.Sign.YMD = November 7, 2014)
(-m = )


Copy given to participant: (m- = )
(Clinician.Confirm.CopyGivenToSubject! = YES!)
(-m = )
)
)