Recognition of this fact has led the Institute to institute a serum collection and banking program for BSL-3 users. Serum samples are commonly used to help determine potential origins of pathogenic exposure or infection. Under this program, employees provide a serum sample at the time of employment, and at the time of termination. Those individuals working with certain biological agents (e.g. HIV) will provide serum samples periodically during the course of employment, consistent with recommendations of the Centers for Disease Control or National Institutes of Health. Each serum sample that is collected is given an identifying number, and is placed in storage. Samples are not analyzed, reviewed or tested unless the donor and the Institute subsequently determine that testing is warranted, and the donor gives written consent to the testing.
By signing this form, you consent to give the sample of blood obtained from you. You agree that the blood sample you provide will belong to The Wistar Institute, but will not be analyzed without your written consent. You have been informed that your participation in this program is voluntary, and not a condition of your employment. You have been given the opportunity to ask any questions you may have about drawing blood or about how your blood sample will be stored and/or used. You acknowledge that you may obtain further information from the Associate Director for Science Administration, The Wistar Institute, 3601 Spruce Street, Philadelphia, PA 19104 (telephone: 215-898-3898). You have the right to obtain a copy of this consent form. After having completely read and understood the above, you hereby agree to have blood drawn by a representative of The Wistar Institute trained for this purpose.
| _________________________ | _____________________________ | |
| Full Printed Name | Signature | |
| _________________________ | _____________________________ | |
| Date | Witness |
Aug 1999