INFORMED CONSENT IN ASSISTED REPRODUCTION TECHNOLOGY
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Issued in accordance with United States and California state privacy and data protection laws
1. PARTICIPANT INFORMATION
Name
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Date of Birth
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MM slash DD slash YYYY
2. PURPOSE OF THE RESEARCH
I consent to participate in a scientific research study in assisted reproduction technologies. I understand that this study involves laboratory work focused on egg thawing, including possible analysis of gametes, clinical information, laboratory data, and phenotypic characteristics.
3. APPLICABLE LEGISLATION
My data will be handled under: • HIPAA (Health Insurance Portability and Accountability Act) • CCPA/CPRA (California Consumer Privacy Act / Privacy Rights Act) • CalGINA (California Genetic Information Nondiscrimination Act)
4. PRIVACY AND DATA PROTECTION
• My identity will remain anonymous. • Data will be securely stored and accessed only by authorized personnel. • I may request clarification or withdraw consent at any time.
5. USE OF PHOTOGRAPHS AND PHENOTYPIC DATA
I understand that donor photographs will be used only by the laboratory team for internal phenotypic classification.
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YES, I AUTHORIZE
NO, I DO NOT AUTHORIZE
6. VOLUNTARINESS
My participation is voluntary, and I may withdraw at any time without consequences.
7. COSTS
There are no costs to me. All research expenses are covered by the research center.
8. CONTACT
Responsible Researcher
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Email
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Phone
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9. DECLARATION AND SIGNATURE
Participant Signature
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Date
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MM slash DD slash YYYY
Researcher Signature
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Date
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MM slash DD slash YYYY