Informed consent for questionnaire and biological samples collection Purpose of the study
Esophageal cancer is the most common cancer in Golestan province and different factors including nutritional deficiencies, ethnicity and environmental exposures might be implicated in the etiology of this disease. To better understand the cause of the esophageal cancer and to reduce its occurrence in Golestan Province, the Digestive Research Center of Tehran University of Medical Science (DDRC), in collaboration with International Agency for Research on Cancer (IARC), has initiated a research study, the Golestan cohort study, to try to find eventual causes of this disease.
All of the study procedure described below will be done only for research purpose. Your participation in this study is voluntary. You may refuse to participate or withdraw from the study at any time without penalty or loss of benefits to which you are otherwise entitled. These confidential results will not be automatically made available to you unless by your request.
Procedure:
If you agree to participate in this study, you will be asked to participate in an interview and provide blood, hair and toenails samples. During the interview, a questionnaire will be administrated to you. This questionnaire contains questions about your age, ethnicity, education, personal and family history of disease, occupation and diet. The total time of the interview will be about 45minutes.
After the interview, a trained nurse will draw 10 ml of blood from your arm, cut a small sample of your hair from the back of your neck, and clip each of your toenails. These samples will be used to test for chemical and genetic markers that may be related to the development of esophageal cancer.
Risks of participation:
No risks are expected from answering the questionnaire or providing hair and nail samples. During the blood collection, you may feel a little pain.
Benefits of participation:
If you agree to participate in this study, you will receive a card that allows you to benefit, for a period of one year, free of charge, of all care provided by Atrak clinic in Gonbad city. In addition, the results of this study may provide insight into the identification of the causes of esophageal cancer in Golestan province. This is a research study and there will be no direct benefits to you other than the satisfaction that people in generations to come may gain from the result of your contribution.
Confidentiality:
The results of your participation, including questionnaire and all analysis on your biological samples, will be kept firmly confidential and your identity will not be made public.
Certification:
I have been given a chance to read this information and all parts of the study have been discussed with me. I consent to being a study participant.
Participant Witness
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