Consent

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Study Case ID:

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NFORMED OWNER CONSENT FORM

FOR COLLECTION OF BLOOD AND URINE SPECIMENS FROM DOGS SUSPECTED OF LEPTOSPIROSIS

STUDY NAME: CANINE LEPTOSPIROSIS SURVEILLANCE IN PUERTO RICO, 2016 – 2017

The Puerto Rico Department of Health (PRDH) and the Centers for Disease Control and Prevention (CDC) are collaborating to determine whether the disease leptospirosis is affecting dogs in Puerto Rico by providing diagnostic tests for dogs suspected of having leptospirosis by a veterinarian. The veterinarian will offer options for treatment based on the results. Leptospirosis can cause serious illness, so a fast and accurate diagnosis is important.

A blood sample will be obtained from dogs to perform a screening test for leptospirosis. If the screening test is positive, additional blood and a urine samples will be obtained to confirm the disease. The additional tests will be conducted at the CDC in Atlanta. Treatment may be started based on the results of the initial screening test.

The purpose of this consent form is to allow us to obtain samples of blood and urine from your dog if your dog is showing symptoms that are consistent with leptospirosis. A small amount of blood will be taken from a vein in the leg, the same amount that is taken to check for heartworms. A urine sample will be taken through the same procedure performed to diagnose bladder infections. The blood and urine will be tested for leptospirosis. The only risks are discomfort from the needle stick and minor bleeding or bruising at the site where the needle is placed. Any blood and urine samples remaining after testing is completed will be stored at CDC and may be tested for additional infectious diseases in the future.

The information you provide to us in the questionnaire and the results of your dog’s tests will be kept secure to ensure your and your pet’s privacy. Only scientists and doctors authorized by PRDH and CDC will have access to your dog’s blood and urine samples.

CONSENT

I consent to providing the information requested in the questionnaire and to have blood and urine samples collected from my dog to test for leptospirosis. I understand why this request is being made and what PRDH and CDC will do with my dog’s blood and urine. I understand that the result of the screening test will be used to assist the veterinarian in providing options for the care and treatment of my dog. The results of the tests will be made available to me at no charge, but I will be financially responsible for the care of my dog. I understand that the blood and urine samples will be stored at CDC.

I have read the information about this procedure and freely give my consent.

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The PRDH and CDC thank you for your time and generosity in agreeing to participate. You are helping to provide information that is very important to animal public health.