Consent Form (kidney)

Study Case ID:

Place pre-printed label here or write ID number

INFORMED OWNER CONSENT FORM FOR COLLECTION OF KIDNEY SPECIMEN

STUDY NAME: CANINE LEPTOSPIROSIS SURVEILLANCE IN PUERTO RICO, 2016 – 2020

Your dog has tested positive for leptospirosis on a rapid screening test or your veterinarian has a strong clinical suspicion that your dog has leptospirosis. If your dog has died or is being euthanized, we are further requesting your consent to allow us to obtain a small piece of kidney (approximately 2x2 cm, olive sized) to test for the bacteria that causes leptospirosis. If your dog is being euthanized, the kidney specimen will be obtained after the euthanasia procedure thus your dog will not experience any pain or discomfort.

The kidney specimen will be tested at CDC and your veterinarian will be notified of the test results; results may not be available for several months. 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 CDC will have access to your dog’s kidney sample and test results. After testing is completed, unused portions of the kidney specimen will be stored at CDC and may be tested for additional infectious diseases in the future.

CONSENT

I consent to having a small piece of kidney collected from my dog. I understand why this request is being made and what CDC will do with my dog’s kidney specimen. I understand that the result of this testing might assist my veterinarian in the care and treatment of other dogs, and may help confirm the diagnosis of leptospirosis in my dog. The results of the test will be made available to me at no charge. I understand that the kidney specimens will be stored at CDC.

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

Owner signature__________________________________ Date________________

(Print full name)___________________________________

The CDC and Puerto Rico Veterinary Medical Association 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.