Form to be on headed paper

 Consultee declaration form (England and Wales) 

Version 4.1, 8th February 2017

Identification and characterization of the clinical toxicology of novel psychoactive substances (NPS) by laboratory analysis of biological samples from recreational drug users.

Consultee declaration Form

Name of Lead Researcher: Dr 

Name of potential participant
Please initial box
1.		I understand that I am being consulted about [name of potential participant]’s participation in this research project, because he/she is not currently able to consent for him/herself 

2.		I have read and understood the information sheet provided (Version 4.1, 8th February 2017). I have had the opportunity to ask questions about the study and understand what is involved.

3.		I understand that participation is voluntary and that that he/she is free to withdraw at any time, without giving any reason, without his/her medical care or legal rights being affected. I also understand that they will be asked to give consent for themselves or decline participation when they are able.

4.		I understand that sections of his/her medical notes may be looked at by responsible individuals from the participating or sponsoring NHS Trusts or from regulatory authorities where it is relevant to him/her taking part in research. 		
			
5.		In my opinion he/she would have no objection to taking part in the above study.

_______________________	    	         /        /          	______________________
Name of consultee (please print)                  Date	            		Signature

Relationship to participant            	 ______________________________________________	            

________________________	   	         /        /          	_________________________
Person undertaking consultation	(please print)            Date  	Signature     

When completed: one copy to patient; original copy to Site Investigator File; one copy for medical records.   THANK YOU