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YOUTH ASSENT TO PARTICIPATE IN RESEARCH
(13-17 years of age)
Technical title: HIV Replication and Thymopoiesis
in Adolescents � Substudy
Principal
Investigator:� Paul Krogstad,
M.D.
Co
Investigators: Martin Anderson, M.D., Yvonne Bryson, M.D., Karin Nielsen, M.D.,
and Jaime DeVille, M.D.
UCLA Department of Pediatrics,
If
you don't want to be in this study, you don't have to participate.� Remember, being in this study is up to you
and no one will be upset if you don't want to participate or even if you change
your mind later and want to stop.� Please
talk this over with your parents before you decide whether or not to participate.� We will also ask your parents to give their
permission for you to take part in this study.�
But even if your parents say "yes" you can still decide not to
do this.
This
study is sponsored by a grant from the National Institutes of Health (NIH).
DISCLOSURE
STATEMENT
Your health care provider may be an investigator
of this research protocol, and as an investigator, is interested in both your
clinical welfare and in the conduct of the study.� Before entering in this study, or at any time
during the research, you may ask for a second opinion about your care from
another doctor who is in no way associated with this project.� You are not under any obligation to
participate in any research project offered by your physician.
PURPOSE OF THE STUDY
You have been asked to participate in this sub-study
because you are participating in the main study looking at the function of the
thymus, an organ in your body that makes special cells called T cells to fight
infections.� In this sub-study we are
looking to see how HIV infection affects the thymus.� This will be done by looking at how the
thymus functions in adolescents and young adults who are infected with HIV
versus how it functions in adolescents and young adults, like you, who are not
infected with HIV.� We will do this by
using a special sugar solution or special water that contains a chemical (�a
label�) that is taken into your cells.�
We can then detect the label by testing your blood. The first subjects
who are in the sub-study will receive a labeled sugar solution.� We are not sure if this procedure will allow
us to detect enough of the label in your cells.�
If it doesn�t, the next subjects in the sub-study will receive a special
water solution that contains the label.�
You will receive only the sugar solution or the water solution, not
both, and you will be told which you will receive before you start the
sub-study.
Your participation in this substudy
will last for 1 month. Up to 30 subjects may be enrolled in this substudy, with up to 10 at UCLA.
If you volunteer to
participate in this study, we would ask you to do the following things:
At the month 6 visit of the main study, we would
ask you to stay overnight in the hospital for one night.�� If you will receive the sugar solution, it
will be given to you over a 24 hour period through a needle in one of your
veins.�� You will have a drop of blood
collected from your fingertip or other similar area at 12 hours and again at 24
hours.��� You will also be asked to come
back to the clinic between 4 and 7 days, and between 8 and 14 days after you
receive the sugar solution to have more blood collected (up to 3�� tablespoons at each visit, but it may be less
depending on your body weight).� If you receive
the water solution, you will drink the water solution during your 24 hour stay
in the hospital, and you will get the water solution to take home with
you.� You will be asked to give a urine
sample at the end of your stay.� You will
drink the water solution 2-3 times per week for four weeks.� The investigator or a member of the study
team will call you during the four week period to remind you to drink the water
solution.� You will be asked to come back
to the clinic on day 14 and day 28 after your hospital stay to have up to 3�� tablespoons of
blood collected at each visit, although it may be less blood depending on your
body weight.�
The blood collected will be tested to see how
the labeled sugar or labeled water enters your cells.
POTENTIAL RISKS AND DISCOMFORTS
The risks of this
study are given below.� In addition,
there may be risks that are currently unforeseeable.
If you are given the sugar solution, you will have a needle
in one of your veins for the entire time you�re in the hospital.��� This may cause pain, infection, bruising,
swelling at the site and rarely, fainting.
Drinking the water
solution
If you are given the water solution to drink, you may be
slightly dizzy during the first 24 hours that you drink it.� This is because you will be drinking more
water than you are used to.
Blood drawing may
produce pain, infection, bruising, swelling at the site and rarely, fainting.� When
possible,� the
blood will be drawn at the same time you are having blood drawn for another
reason.
ANTICIPATED BENEFITS TO SUBJECTS
You will not benefit from participating in this study.
ANTICIPATED BENEFITS TO SOCIETY
This study may help physicians to better understand
diseases that decrease the body's ability to fight infections and tailor
appropriate therapy for those conditions thus saving more lives.
ALTERNATIVES TO
PARTICIPATION
An alternative is not to participate.
PAYMENT FOR PARTICIPATION
You will be paid $75 for the overnight stay, $35 when you come back for
the first blood collection, and $35 when you come back for the second blood
collection, for a total of $145 if you complete all three visits.
POSSIBLE COMMERCIAL PRODUCTS
All tissue and/or fluid samples are important to this
research study.� Your sample will be
owned by the
SAMPLE REMAINING AT THE END OF THE STUDY
On the checklist at
the end of this consent form, you will be asked to indicate if you would permit
part of this sample to be shared with other researchers.� If you agree to have your sample shared with
other researchers and later decide to withdraw, we may not be able to retrieve
any or all of your sample from other researchers.� The researcher is not required to store your
sample(s) indefinitely.
INFORMATION ABOUT YOUR SAMPLE
On the checklist
below, you are asked to let us know if you would like to receive information
about the results of this study.� There
are two types of information you may receive:
1.
general information about what this study
found (or conclusions of the study);
2.
specific
information about what the study found about your sample.
You may also choose
not to receive any information.� Research
is a long and complicated process.�
Obtaining general information from a project may take years.� Even if there is general information from a
project, there may not be personal information for every participant.
FINANCIAL OBLIGATION
Neither you nor your
insurance company will be charged for your participation in this research.
PRIVACY AND
CONFIDENTIALITY
The only people who will
know that you are a research subject are members of the research team and, if
appropriate, your physicians and nurses.�
No information about you, or provided by you during the research, will be disclosed to others without your written
permission, except:
-
if necessary to protect your rights or
welfare (for example, if you are injured and need emergency care); or
-
if
required by law.
When the results of
the research are published or discussed in public, no information will be
included that would reveal your identity.
PARTICIPATION AND
WITHDRAWAL
Your participation in
this research is VOLUNTARY. If you choose not to participate, that will not
affect your relationship with UCLA (or
WITHDRAWAL OF PARTICIPATION BY THE INVESTIGATOR
The investigator may
withdraw you from participating in this research if circumstances arise which
warrant doing so.� The investigator will
make the decision and let you know if it is not possible for you to continue.� The decision may be made either to protect
your health and safety, or because it is part of the research plan that people
who develop certain conditions may not continue to participate.
NEW FINDINGS
During the course of
the study, you will be informed of any significant new findings (either good or
bad), such as changes in the risks or benefits resulting from participation in
the research or new alternatives to participation, that might cause you to
change your mind about continuing in the study.�
If new information is provided to you, your consent to continue
participating in this study will be re-obtained.
IDENTIFICATION OF INVESTIGATORS
In the event of a
research related injury or if you experience an adverse reaction, please
immediately contact one of the investigators listed below.� If you have any questions about the research,
please feel free to contact any of the investigators.� They can be reached Monday through Friday,
8:00 AM to 4:30 PM. at the numbers listed below.� You may be asked to leave a message with the
secretary for the investigator to call you back.�
Paul Krogstad, M.D.��������������������������� [redacted]
Martin Anderson, M.D.����������������������� [redacted]
Yvonne Bryson, M.D.������������������������� [redacted
Karin Nielsen, M.D.���������������������������� [redacted]
Jaime DeVille, M.D.���������������������������� [redacted]
After hours, or in
case of emergency, the investigators can be reached through the UCLA page
operator at [redacted].
RIGHTS OF RESEARCH SUBJECTS
You may withdraw your
consent at any time and discontinue participation without penalty.� You are not waiving any legal claims, rights
or remedies because of your participation in this research study.� If you have questions regarding your rights
as a research subject, you may contact the Office for Protection of Research
Subjects, 2107
|
SIGNATURE OF
PARENT/LEGAL GUARDIAN |
I have read (or
someone has read to me) the information provided above.� I have been given an opportunity to ask
questions and all of my questions have been answered to my satisfaction.� I have been given a copy of this form, as
well as a copy of the Subject's Bill of Rights.
BY SIGNING THIS FORM, I WILLINGLY AGREE TO PARTICIPATE IN
THE RESEARCH IT DESCRIBES.
________________________________________
Name
of Subject
______________________________________________��������������� ______________
Signature of Subject����������������������������������������������������������������������������� Date
________________________________________
Name of Parent/Legal Guardian
______________________________________________��������������� ______________
Signature of Parent/Legal Guardian������������������������������������ Date
�
SHARING
OF SAMPLES
Please check the
appropriate box below and initial:
�_______I agree
to have my tissue/fluid sample shared with other researchers.
�_______I do not
want my tissue/fluid sample shared with other researchers.
�
INFORMATION
ABOUT MY SAMPLE
Please indicate by
checking and initialing the category below what type of information you want to
receive.� It is your responsibility to
let the investigator know if your address and/or telephone number changes.� The contact information is in this informed
consent form under "Identification of Investigators".
�_______General
Information about what the study found
�_______Specific
Information about what the study found about me
�_______I do not
want any information about my sample
|
SIGNATURE OF
INVESTIGATOR |
I have explained the
research to the subject or his/her parent/guardian, and answered all of his/her
questions.� I believe that he/she
understands the information described in this document and freely consents to
participate.
________________________________________
Name
of Investigator
________________________________________��� _____________________________
Signature of
Investigator����������������������������������������������� Date
(must be the same as subject�s)