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Before we can move forward with the transfer of samples we will need to obtain permission in the form of Informed Consent.
Prior to tissue banking we will arrange a time to go over the consent form and you will have the opportunity to ask any questions you may have about participating. Consent forms are currently provided in English and Spanish. Additional translations can be made available if adequate time is provided before the transfer. 2 original copies of the consent forms will need to be signed. One signed copy will accompany the samples to the tissue bank and the other signed copy will stay at the originating hospital.
- Tissue Bank Adult Consent:
For tissue bank donors above 18 years of age
- Tissue Bank Adult Consent (Spanish):
Spanish translation consent form for tissue bank donors above 18 years of age
- Tissue Bank Parental Consent-Youth Assent (English):
For parents or legal guardians of tissue bank donors under 18 years of age
- Tissue Bank Parental Consent-Youth Assent (Spanish):
Spanish translation consent form for parents or legal guardians of tissue bank donors under 18 years of age.
- Tissue Bank Child Assent:
For tissue bank donors that are minors 7 years of age or older
UCLA HIPAA Authorization Form:
This is permission from your hospital or medical care provider to release medical information. To protect confidentiality all personally identifiable information is stripped from any donated material entering the tissue bank and it is replaced with a unique code. The tissue bank will collect the following non-identifiable clinical information: Age at seizure onset, age at surgery, seizure frequency at time of surgery, list of anti-epileptic drugs (AEDs) and immune therapy prior to surgery, de-identified MRI images and de-identified surgical pathology report.