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It outlines how the principal investigator will use the participant’s information and emphasizes privacy protection, stating that identity will not be disclosed when the report is published or presented. It describes confidentiality protections, a limited risk of loss of confidentiality, no direct personal benefit, no additional costs, and no compensation. Participation is voluntary, with withdrawal not possible once the report is written and published.","Consent Form for Case Report\nThis form is best put on clinic letterhead.\nCase Report:\nPrincipal Investigator:\nYou are being asked to consider allowing __________ to use information about _________ to write what is called a case report.  Case reports are typically used to share new unique information experienced by one patient during his/her clinical care that may be useful for other physicians and members of a health care team.  A case report may be published (in print and/or via internet dissemination) for others to read, and/or presented at a conference.  This form explains the purpose of this case report.  Please read this form carefully and take your time to make your decision and ask any questions that you may have.\nThe purpose of this case report is to inform other physicians about _______\nYour information being used for this case report includes your patient characteristics such as ________\n_______ is obligated to protect your privacy and not disclose your personal information (information about you and your health that identifies you as an individual e.g. name, date of birth, medical record number). When the case report is published or presented, your identity will not be disclosed.\nAlthough your personal information collected or obtained will be kept confidential and protected to the fullest extent of the law, there is a limited risk associated with this case report that could result in a loss of confidentiality by virtue of your unique experience.  \u000b\u000bYou will not directly benefit from participating in this case report.  The information that can be shared with other health care professionals, however, may improve the care that is received by others in the future.\nAllowing your information to be used in this case report will not involve any additional costs to you. You will not receive any compensation.\nTaking part in this case report is your choice (voluntary). You may choose not to take part or you may change your mind at any time.  However, once the case report is written and published, it will not be possible for you to withdraw it.  Your decision will not result in any penalty or loss of benefits to which you are entitled including the quality of care you receive.\nYou will be told about any new information relating to this case report that may affect you.\nYour signature below means that you have read the above information about this Case Report and have had a chance to ask questions to help you understand how your information will be used and that you give permission to allow your information to be used in this case report.\nIf you have any questions please contact _____________________\nSUBJECT CONSENT TO PARTICIPATE\nCase Report Title:\nName of Participant:  _______________________________________\nParticipant/Substitute decision-maker\nBy signing this form, I confirm that:\nThe case report has been fully explained to me and all of my questions have been answered to my satisfaction\nI have been informed of the risks and benefits, if any, of allowing my information to be used in this case report\nI have been informed that I do not have to participate in this case report\nI have read each page of this form\nI authorize access to my personal health information (medical record) as explained in this form\nI have agreed to participate in this case report\n__________________________        _______________________        _____________________\nName of Participant/Substitute      \tSignature\t\t\t          Date\nDecision-maker (print)","cbCaif0rmE6h9N6d","https://ap.wps.com/l/cbCaif0rmE6h9N6d","doc",28672,2,"English","en",105,"# Consent Form for Case Report\n## Case Report Purpose and Information Use\n## Privacy, Risks, Benefits, and Costs\n## Voluntary Participation and Withdrawal\n## Subject Consent to Participate\n## Signature and Contact Information","[{\"question\":\"What is the purpose of this case report and how will the participant’s information be used?\",\"answer\":\"The form states that the case report shares unique clinical information learned during care and may be published or presented. 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