Aug 29, 2012

Consent Form for Thyroid Examination for Fukushima Prefecture Resident Health Management Survey

The left side of this form is an announcement about the implementation of thyroid examination as part of Prefecture Resident Health Management Survey.

The box contains details of the examination such as the examinee’s name, date, place, and type (a free, 5-minute ultrasound examination of thyroid) of examination, and how to apply for it.  Under item 5, it states that “As a rule, the thyroid examination will not be performed without submission of the consent form.”

The right side of this form is the actual consent form.  The box contains personal information, such as name of the examinee and the legal guardian, address, phone number, height and weight of the examinee, and the method of transportation to get to the examination site.  The part above the box is translated as follows.


Consent Form

To:  Fukushima Prefecture Governor and Municipal University Corporation Fukushima Medical University President

“This thyroid examination is intended to assess current thyroid conditions in order to implement health management of children.  You will be notified of the examination result, and the data will be stored by Municipal University Corporation Fukushima Medical University.  There is a possibility that part of the data, kept anonymous in consideration of privacy, might be publicized and utilized as basic material for statistical processing and continuous health management.”

Upon understanding the above statement, I give consent to Prefecture Resident Health Management Survey Thyroid Examination for the following examinee under my legal guardianship.

Moreover, I append that the consent was given under the following conditions.
Consent conditions:

1. I (or the examinee once becoming a legal adult) may be able to revoke this consent at my (or examinee’s) convenience.

2. I and the examinee will not receive any disadvantage from the consent being revoked.

3. I (or the examinee once becoming a legal adult), may obtain information related to the examinee himself/herself anytime I or the examinee should wish.

4. Any personal information provided for this survey will be strictly confidential.

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