AGDS_CellO eConsent Form

Title	Australian Genetics Depression Study: Anti-depressant Cell-omics Study
Short Title	AGDS-CellO
Protocol Number	2023/HE000050
Project Sponsor	The University of Queensland
Coordinating Principal Investigator	Professor Naomi Wray
Associate Investigator(s)	Professor Ian Hickie Professor Nick Martin Dr Sonia Shah Professor Sarah Medland Dr Enda Byrne Dr Jacob Crouse Dr Brittany Mitchell
Location	The University of Queensland

Participant Details

Participant Invite Code *

ⓘ This can be found on the invitation email you received to participate in this study.

Gender *

First Name *

Middle Name

Last Name *

Date of Birth *

Please type the date in yyyy-mm-dd format. (e.g. 2023-07-19)

Email Address *

Mobile Number *

Residential Address

Street Address *

Suburb *

State *

Postcode *

Postal Address (If different to residential address)

Street Address

Suburb

State

Postcode

Declaration by Person Responsible

I have read the Participant Information Sheet, or someone has read it to me in a language that I understand. I agree to participate and provide information and biological samples as required. I consent to participate under the following conditions:

I understand the purposes, procedures and risks of the research described in the project.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.
I have agreed to provide biological samples and their use has been explained and accepted by me including the generation of genetic information by sequencing my genome.
I understand that all data pertaining to me including my DNA I have provided (but not my name or address) may be made available to researchers in the future, some of whom may have commercial interests.
I donate my biological sample freely for these purposes and waive any claim to commercial rights arising from this work.
I understand that I will be given a signed copy of this document to keep.
I understand that data from my previous participation in AGDS QIMRB study related to this research will be linked to this study.
I freely agree to participating in this research project as described and understand that I am free to withdraw at any time during the research project without affecting my future health care.

Genetic Research Findings

Please select only one option:

Genetic Findings *

I request that genetic research findings of health significance identified in my DNA be shared with a health professional of my choosing and understand that validation of these will require an additional biological sample to be provided.

I do not want genetic research findings of health significance identified in my DNA to be shared with a health professional. I understand this means I will not receive any information through my participation in this project of genetic research findings that may be of importance to me and/or my family.

Storage and Future Use of Biological Samples

In respect to the storage and future use of my samples for:

1. Genetic analysis

I give permission for the use of my samples and its derivatives for the purpose of:

sample1 *

This specific research only

This specific research and other closely related mental health research

This specific research and any future research projects that may or may not be related to mental health research

2. Peripheral blood mononuclear cells (PBMCs) for downstream application of generating lymphoblastoid cell lines (LCLs)

I give permission for the use of my samples and its derivatives for the purpose of:

sample2 *

This specific research only

This specific research and other closely related HREC approved mental health research

I do not consent to any of the above uses of my sample

3. Peripheral blood mononuclear cells(PBMCs) for the downstream application of generating induced Pluripotent Stem Cells (iPSC) lines and differentiated organoids

I give permission for the use of my samples and its derivatives for the purpose of:

sample3 *

This specific research only

This specific research and other closely related HREC approved mental health research

I do not consent to any of the above uses of my sample

Other General Information

I agree to be recontacted for additional health information related to this study *

Yes

I would like to receive results from this study *

Yes

I agree to be recontacted for future HREC approved research projects *

Yes

Declaration by the participant

Signature

Full Name of Participant * (please print)

Date *

Please type the date in yyyy-mm-dd format. (e.g. 2023-07-19)

Note: All parties signing the consent section must date their own signature

V1.2_27 June 2023

Leave this field blank

Human Studies Research Portal

Warning message

Please complete Step-1: Participation Information prior to this step.

Declaration by Person Responsible