CONSENT FORM FOR USE OF SAMPLE IN RESEARCH

Dr Wilton at the University of NSW is collecting blood and buccal samples from dogs for the purposes of identification of genetic diseases in dogs.  DNA will be extracted from the samples and stored at UNSW.  The major diseases under study are ceroid lipofuscinosis (CL) and collie eye anomaly (CEA).  The samples may be used in the study of other diseases if the research is extended in the future unless specific instructions are given to the contrary.  Both affected and unaffected animals are required for the research, the latter as controls.  The disease status of any samples submitted will be kept confidential.  All samples will be coded on arrival and in all subsequent work will only be identified by the codes.  The reference database with the animal identification will be kept in a secure place in the Chief Investigator’s office.

If you agree to submitting a sample for this research under these conditions please fill in and sign the statement below and return it with the sample.

I,  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

            (name)

of  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

            (address)

agree to the use of the sample from

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

            (name of dog)

to be used in the research into genetic diseases in dogs as set out above.

I  agree to the sample being used in studies other than CL and CEA:     (  YES  /  NO  )

I declare that I am the owner of the dog or have permission from the owner to make this declaration. If you are not the owner, please supply details for the owner in addition to your own.

Signature                                                                                  Date

Phone Number

Email Address

Pedigree:

Sire                                                                              Dam

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