Identification of a Novel 29-Gene-Based Subtype of Hepatocellular Carcinoma and Its Correlation With Immunotherapy Efficacy
Conditions: Primary Hepatocellular Carcinoma
Sponsor: Junjie Xu

Research plan
Study name
Study on the Identification of New Subtypes of Liver Cancer Based on 29 Genes and the
Correlation with the Efficacy of Immunotherapy
Research Unit
Sir Run Run Shaw Hospital, Zhejiang University School of Medicine
Research Department
Department of General Surgery
Principal Investigator
Xu Junjie
Protocol Version Number
V1.0
Protocol Version Date
July 13, 2025
Study on the Identification of New Subtypes of Liver Cancer Based on 29 Genes and the
Correlation with the Efficacy of Immunotherapy
I. Research Background
Liver cancer is one of the leading causes of cancer - related deaths worldwide. Its
significant heterogeneity makes it difficult for traditional diagnosis and treatment models
to meet the needs of individualized precision treatment. The application of immune
checkpoint inhibitors (ICI) has brought breakthrough progress to liver cancer treatment,
but there are still severe challenges in clinical practice. Although the dual - drug
combination immunotherapy regimen has been widely used clinically, about 60% of
patients will still experience primary or secondary drug resistance, resulting in significant
differences in patients' treatment benefits.
There are two key bottlenecks in the current field that urgently need to be broken through,
as follows:
(1) Lack of precise typing tools: The existing clinical and molecular typing systems
cannot stably distinguish subtypes sensitive to immunotherapy, and it is difficult to
provide reliable references for clinical decision - making, making it difficult to achieve
precise application of immunotherapy;
(2) Lag in clinical translation process: Although a variety of immune checkpoint inhibitors
have been clinically promoted and used, differentiated treatment strategies for different
subtypes have not been established, and there is a lack of typing - guiding schemes
verified by multiple centers.
To solve the above problems, this study intends to systematically develop a liver cancer
typing system based on gene sets. The specific process is as follows: First, collect tumor
and adjacent non - tumor tissue samples from patients with hepatocellular carcinoma,
and perform whole - transcriptome sequencing to obtain transcriptome data; calculate
the gene expression level of each patient sample based on the sequencing results, and
then divide hepatocellular carcinoma into several subtypes through cluster analysis; map

these subtypes to the TCGA HCC cluster respectively, and screen out the subtypes that
cannot be completely matched as new subtypes; further analyze the differential genes
between the new subtypes and other subtypes. The screening criteria are: the ratio of
gene expression between the new subtype and other subtypes > 4, the false discovery
rate (FDR) < 0.01, and the gene expression in the new subtype > 1 and < 1 in other
subtypes. Through this method, this study finally obtained a set of differential genes
containing 29 genes.
Based on this, this study plans to use this 29 - gene set as a standard, obtain frozen
surgical tissues from liver cancer patients for transcriptome sequencing, type the
patients, and compare the differences in immunotherapy response between the new
subtype and other subtypes at the large - sample level, aiming to provide a basis for
precise immunotherapy of liver cancer.
II. Research Objectives
Evaluate the differences in immunotherapy response (including indicators such as
objective response rate, disease control rate, and progression - free survival) between
the new subtype defined by the 29 - gene set system and other subtypes, and confirm
that patients with the new subtype have a higher response rate to immunotherapy.
III. Research Design and Methods
3.1 Research Objects
This study intends to include patients diagnosed with primary hepatocellular carcinoma
who are treated in multiple centers including Sir Run Run Shaw Hospital, Zhejiang
University School of Medicine (the leading unit). The relevant inclusion and exclusion
criteria are as follows.
3.1.1 Inclusion Criteria
①≥18 years old.
②Patients who are treated in multiple centers including Sir Run Run Shaw Hospital,
Zhejiang University School of Medicine (the leading unit) and diagnosed with primary
hepatocellular carcinoma by surgical pathological histology.
③
They have received targeted drug combined with immune checkpoint inhibitor
treatment after the specimen collection time point (post - surgery or post - puncture) (that
is: local treatments such as TACE, ablation, etc. are allowed before the start of targeted -
immunotherapy combination treatment, but an interval of ≥4 weeks from the targeted -
immunotherapy treatment is required).
④Have measurable tumor lesions at the observation start point (according to RECIST
1.1 criteria), and can judge the tumor response status (including complete response CR,
partial response PR, stable disease SD, or progressive disease PD) through imaging
examination during the observation (such as post - treatment evaluation).
⑤Have accessible frozen tumor tissue samples from surgical resection (sample volume
≥3g); or tumor tissue samples obtained by puncture (puncture samples need to meet
the pathological diagnosis requirements, and the sample quality can support subsequent
transcriptome sequencing and analysis).
⑥Voluntarily participate in this study and sign the informed consent form. If the subject

is unable to read and sign the informed consent form due to incapacity and other
reasons, their guardian shall act as the agent for the informed process and sign the
informed consent form. If the subject is unable to read the informed consent form (such
as illiterate subjects), a witness shall witness the informed process and sign the informed
consent form.
3.1.2 Exclusion Criteria
①
Received any local treatment during the targeted - immunotherapy combination
treatment (including during treatment and within 4 weeks after treatment interruption),
including:
Transcatheter arterial chemoembolization (TACE), transcatheter arterial embolization
(TAE), drug - eluting bead transcatheter arterial chemoembolization (DEB - TACE) and
other vascular interventional therapies;
Radiofrequency ablation, microwave ablation, cryoablation, laser ablation and other
ablation therapies;
Stereotactic body radiation therapy (SBRT), three - dimensional conformal radiation
therapy, intensity - modulated radiation therapy and other local radiation therapies;
Intratumoral injection therapy, high - intensity focused ultrasound (HIFU) and other local
physical/chemical therapies.
②
Local treatment was initiated before the start of targeted - immunotherapy
combination
treatment,
and
the
local
treatment
continued
into
the
targeted
-
immunotherapy treatment period (that is, there was an overlap between local treatment
and targeted - immunotherapy treatment or the interval was < 4 weeks).
③Complicated with other active malignant tumors (except for those with cured basal
cell carcinoma of the skin, carcinoma in situ of the cervix, and papillary thyroid carcinoma
with no recurrence for more than 5 years after surgery).
④Severe impairment of important organ functions:
Liver function: Child - Pugh class C, or total bilirubin > 3 × ULN;
Renal function: Serum creatinine > 1.5 × ULN and estimated glomerular filtration rate
(eGFR) < 50 ml/min;
Cardiac function: New York Heart Association (NYHA) cardiac function class Ⅲ- Ⅳ, or
left ventricular ejection fraction (LVEF) < 50%.
⑤Have uncontrolled active infections, including:
Hepatitis B virus DNA > 2000 IU/ml (without receiving antiviral treatment);
Hepatitis C virus RNA positive and without receiving antiviral treatment;
Active tuberculosis infection, septicemia, etc.
⑥
Have a history of autoimmune diseases and currently still need to use systemic
glucocorticoids (prednisone > 10 mg/day) or other immunosuppressive therapies.
⑦Pregnant or lactating women, or patients planning to become pregnant during the
study.
⑧
Have a definite history of allergy to the targeted drugs or immune checkpoint
inhibitors involved in the study.
⑨The researcher believes that there are other factors that may affect the judgment of
treatment response (such as uncontrolled hypertension, coagulation dysfunction,
simultaneous use of other antineoplastic drugs during targeted - immunotherapy

treatment, etc.).
3.1.3 Withdrawal Criteria
①
The subject voluntarily requests to withdraw from the study and signs a written
withdrawal statement.
②Severe adverse events occur during the study (such as grade 3 or above immune -
related adverse reactions, severe infections, etc.), and after the researcher's evaluation, it
is considered that continued participation in the study may endanger the subject's safety.
③The subject does not comply with the research protocol, including but not limited to:
failure to follow up at the specified time, refusal to complete necessary examinations,
unauthorized acceptance of other antineoplastic treatments, etc.
④It is found during the study that the subject does not meet the inclusion criteria of this
study (such as the previous treatment history does not meet the requirements found in
the baseline data verification).
⑤
The subject is unable to continue participating in the study due to disease
progression, death, and other reasons.
⑥
The study is terminated in advance (such as protocol revision, ethical committee
requiring termination, etc.).
3.2 Research Content
3.2.1 Data Acquisition System
3.2.1.1 Molecular Feature Collection
(1) Sample Source: Obtain frozen tumor tissues (≥3g) from patients through surgical
resection or tumor tissue samples obtained by puncture (puncture samples need to meet
the pathological diagnosis requirements, and the sample quality can support subsequent
transcriptome sequencing and analysis). Use the Illumina HiSeq platform for RNA - seq
sequencing. The raw data undergoes quality control (FastQC), alignment (HISAT2),
quantification (FeatureCounts), and differential expression analysis (DESeq2) to screen
for differential genes with FDR < 0.01 and expression ratio > 4. This part of the testing is
outsourced to Hangzhou 迪安Medical Laboratory Center Co., Ltd. for testing.
(2) Typing Algorithm: Perform hierarchical cluster analysis based on the 29 - gene set,
and divide the subjects into a new typing cohort (unable to map to the TCGA HCC cluster)
and other typing cohorts.
3.2.1.2 Clinical Data Integration
Structured extraction of subjects' baseline data (age, gender, Child - Pugh class, etc.),
treatment information (targeted - immunotherapy combination regimen, dosage, and
cycle, etc.), imaging evaluation (enhanced CT/MRI reports, etc.), and survival status (last
follow - up date or death time, etc.) from the electronic medical record system.
Simultaneously collect AFP (electrochemiluminescence method), PIVKA - II (enzyme -
linked immunosorbent assay), and liver function biochemical data (total bilirubin, albumin,
INR, etc.). The detection frequency matches the imaging evaluation cycle (that is,
equivalent to clinical routine).
3.2.2 Immunotherapy Response Evaluation System
3.2.2.1 Primary Observation Indicators
(1) Time to Progression (TTP)
Definition: The time from the start of targeted - immunotherapy combination treatment to

the first time meeting the mRECIST progression criteria.
Evaluation Criteria:
Target lesions: The sum of the diameters of arterial - phase enhancement increases by
≥20% compared to the baseline and the absolute value ≥5mm;
Non - target lesions: New lesions appear or existing non - target lesions have definite
progression;
Distant metastasis: New occurrences of lung, bone, or lymph node metastases.
(2) Objective Response Rate (ORR)
Definition: The proportion of patients achieving complete response (CR, disappearance
of arterial - phase enhancement in all target lesions) and partial response (PR, the sum of
the diameters of target lesions is reduced by ≥30%).
Evaluation Time: For each line of targeted - immunotherapy combination treatment
regimen received by the patient, the determination is made simultaneously at Week 8,
Week 16, Week 24 of the regimen treatment, and at disease progression (or regimen
termination). If the patient changes the targeted - immunotherapy treatment regimen due
to poor efficacy, the treatment cycle of the new regimen needs to be recorded separately
(Weeks 8, 16, 24 are recalculated from the start time of the new regimen), and the CR/PR
status is evaluated at the corresponding time points. In the final ORR calculation, the
CR/PR status achieved by the patient in a certain regimen only corresponds to the
treatment cycle and evaluation time of that regimen, that is, it is clearly associated with
the efficacy data of the specific targeted - immunotherapy combination regimen
(including the first regimen or the subsequent new regimens).
3.2.2.2 Secondary Observation Indicators
(1) Core Indicators of Immunotherapy Response
①Progression - Free Survival (PFS)
Definition: The time from the start of targeted - immunotherapy combination treatment to
the first disease progression (determined according to mRECIST) or death from any
cause, whichever occurs first.
Evaluation Method: Combine imaging examinations (once every 8 weeks) and survival
status follow - up, and use the Kaplan - Meier method to perform Log - rank test to
compare the differences between groups.
②Overall Survival (OS)
Definition: The time from the start of targeted - immunotherapy combination treatment to
the patient's death from any cause; for lost - to - follow - up patients, the last follow - up
date is used as the censored data.
Evaluation Method: Record the survival status through regular telephone/outpatient
follow - up, draw survival curves, and analyze the differences between groups.
Dynamic changes of tumor markers.
(2) Dynamic Monitoring Related to Tumors
Dynamic changes of tumor markers
Monitoring Indicators: Alpha - fetoprotein (AFP), protein induced by vitamin K absence or
antagonist - II (PIVKA - II), detected once at baseline and every 4 weeks.
Judgment Criteria: An increase of ≥
20% compared to the baseline and lasting for
more than 4 weeks, combined with imaging results to assist in predicting the progression

risk (such as the early warning value of marker increase before imaging progression).
(3) Evaluation of Treatment - Related Status
①Correlation with Liver Function Status
Evaluation Nodes: Collect liver function data (Child - Pugh class, total bilirubin, albumin,
INR) simultaneously when disease progresses.
Analysis Logic: Compare with baseline liver function, exclude interfering factors such as
drug - induced liver injury, and evaluate the direct impact of tumor progression on liver
function injury.
②Survival Analysis after Progression
Record Content: Treatment adjustment plans after disease progression (changing
targeted drugs, adding local treatments, etc.).
Analysis Indicators: Post - progression survival (PPS, the time from disease progression
to death or the end of the study), and analyze the impact on survival by combining
differences in treatment plans.
3.2.3 Statistical Analysis
3.2.3.1 Data Description and Comparison between Groups
Measurement data (such as age, AFP level, liver function indicators, etc.): Normally
distributed data are expressed as mean ± standard deviation, and independent sample
t - test (for two groups) or analysis of variance (for multiple groups) is used for
comparison between groups; non - normally distributed data are expressed as median
(interquartile range), and Mann - Whitney U test (for two groups) or Kruskal - Wallis test
(for multiple groups) is used.
Count data (such as immunotherapy response type, typing results, etc.): Expressed as
frequency (percentage), and chi - square test is used for comparison between groups; if
the frequency of a cell < 5, Fisher's exact probability method is used instead.
3.2.3.2 Survival Analysis
Use the Kaplan - Meier method to draw survival curves of time to progression (TTP) and
post - progression survival (PPS), and compare the survival differences between the new
typing cohort and other typing cohorts through Log - rank test; use the Cox proportional
hazards regression model to analyze the impact of 29 - gene set typing and clinical
factors (such as Child - Pugh class, changes in tumor markers) on the progression risk.
3.2.3.3 Immunotherapy Response Analysis
The differences between groups in objective response rate (ORR) and disease control
rate (DCR) are verified by chi - square test or Fisher's exact probability method, and the
efficacy judgment follows the mRECIST criteria.
3.2.3.4 Analysis Tools
Use GraphPad Prism 10 for data visualization and basic statistics, and R language
(survival, ggplot2 packages) for survival analysis and regression modeling. A P - value <
0.05 is used as the criterion for judging that the difference is statistically significant.
3.2.4 Protection Measures for Vulnerable Groups
The vulnerable groups that may be involved in this study include the mentally
ill/cognitively impaired/critically ill patients/elderly/illiterate, etc. This study will take the
following measures to protect their interests: 1) Ensure that the subjects are fully
informed. If the subject is unable to read and sign the informed consent form due to

incapacity, their guardian shall act as the agent for the informed process and sign the
informed consent form. If the subject is unable to read the informed consent form (such
as illiterate subjects), a witness shall witness the informed process and sign the informed
consent form. 2) If it is a critically ill patient, the researcher will closely monitor the vital
signs of such subjects, and report in a timely manner once there is a situation.
IV. Sample Size Calculation
This study plans to include subjects from 10 top - three hospitals nationwide. Calculate
the new typing score of HCC for each sample through the 29 - gene signature. It is
estimated that there will be 100 cases in the new typing cohort and 250 cases in other
typing cohorts.
Therefore, the final planned total sample size of this study is 350 cases.
V. Data Management and Confidentiality
All records related to the subject's identity will be kept confidential, and these materials
will not be disclosed outside the scope permitted by relevant laws and/or regulations.
VI. Informed Consent
For the prospective observational study part involved in this study, before the subjects
are included in this study, the researcher responsible for the informed consent
discussion should introduce the purpose, nature, procedure, and possible benefits and
risks of this study to them in written form completely and comprehensively. The subjects
should be informed that they have the right to withdraw from the study at any time.
Before inclusion, each subject should be fully informed and have sufficient time to
consider whether to participate. Only after the subject voluntarily participates and signs
the informed consent form can they be included in this study.
For the retrospective study part involved in this study, if it only involves the use of
previously saved clinical data and biological specimens, does not interfere with the
clinical diagnosis and treatment process, and will not have an adverse impact on the
health of the subjects. During statistical analysis, the identity of the subjects is
represented by codes, and there is no disclosure of the subjects' privacy and personal
information. This part of the study does not involve commercial interests and can apply
for exemption from informed consent.
VII. Adverse Events and Related Handling Measures
For the prospective observational study part involved in this study, only clinical data of
the subjects are collected, no additional biological samples are collected, and the clinical
diagnosis and treatment process is not interfered with, which will not have an adverse
impact on the health of the subjects.

Informed Consent Form
Protocol Name
Study on the Identification of New Subtypes of Liver Cancer Based on 29 Genes and the
Correlation with the Efficacy of Immunotherapy
Version Number
V1.0
Version Date
July 13, 2025
Dear Subject,
We invite you to participate in the “Study on the Identification of New Subtypes of Liver
Cancer Based on 29 Genes and the Correlation with the Efficacy of Immunotherapy”
which has been reviewed and approved by the Ethics Committee of Sir Run Run Shaw
Hospital, Zhejiang University School of Medicine.
This informed consent form will provide you with some information to help you decide
whether to participate in this clinical study. Your participation in this study is completely
voluntary, and your decision will not affect your normal medical treatment rights and
benefits in our hospital. If you choose to participate in this study, our research team will
do our best to ensure your safety and rights during the research process.
Please read it carefully. If you have any questions, please raise them to the researcher in
charge of this study.
I. Research Background, Significance and Research Objectives
1.1 Background and Significance
Liver cancer is one of the leading causes of cancer - related deaths worldwide. Its
significant heterogeneity makes it difficult for traditional diagnosis and treatment models
to meet the needs of individualized precision treatment. The application of immune
checkpoint inhibitors (ICI) has brought breakthrough progress to liver cancer treatment,
but there are still severe challenges in clinical practice. Although the dual - drug
combination immunotherapy regimen has been widely used clinically, about 60% of
patients will still experience primary or secondary drug resistance, resulting in significant
differences in patients' treatment benefits.
There are two key bottlenecks in the current field that urgently need to be broken through,
as follows:
(1) Lack of precise typing tools: The existing clinical and molecular typing systems
cannot stably distinguish subtypes sensitive to immunotherapy, and it is difficult to
provide reliable references for clinical decision - making, making it difficult to achieve
precise application of immunotherapy;
(2) Lag in clinical translation process: Although a variety of immune checkpoint inhibitors
have been clinically promoted and used, differentiated treatment strategies for different

subtypes have not been established, and there is a lack of typing - guiding schemes
verified by multiple centers.
To solve the above problems, this study intends to systematically develop a liver cancer
typing system based on gene sets. The specific process is as follows: First, collect tumor
and adjacent non - tumor tissue samples from patients with hepatocellular carcinoma,
and perform whole - transcriptome sequencing to obtain transcriptome data; calculate
the gene expression level of each patient sample based on the sequencing results, and
then divide hepatocellular carcinoma into several subtypes through cluster analysis; map
these subtypes to the TCGA HCC cluster respectively, and screen out the subtypes that
cannot be completely matched as new subtypes; further analyze the differential genes
between the new subtypes and other subtypes. The screening criteria are: the ratio of
gene expression between the new subtype and other subtypes > 4, the false discovery
rate (FDR) < 0.01, and the gene expression in the new subtype > 1 and < 1 in other
subtypes. Through this method, this study finally obtained a set of differential genes
containing 29 genes.
Based on this, this study plans to use this 29 - gene set as a standard, obtain frozen
surgical tissues from liver cancer patients for transcriptome sequencing, type the
patients, and compare the differences in immunotherapy response between the new
subtype and other subtypes at the large - sample level, aiming to provide a basis for
precise immunotherapy of liver cancer.
1.2 Research Objectives
Evaluate the differences in immunotherapy response (including indicators such as
objective response rate, disease control rate, and progression - free survival) between
the new subtype defined by the 29 - gene set system and other subtypes, and confirm
that patients with the new subtype have a higher response rate to immunotherapy.
II. Research Process
2.1 Basic Research Situation
This study is a prospective observational clinical study. The expected number of subjects
participating in this center is 100. If you agree to participate in this study, you need to
sign this informed consent form. After that, we will judge the inclusion and exclusion
criteria. If you meet the inclusion criteria and do not meet the exclusion criteria, you will
be included in this study.
2.2 Observation Indicators
This study will structurally extract the following data of yours from the electronic medical
record system. The detection frequency matches the imaging evaluation cycle (that is,
equivalent to clinical routine).
(1) Baseline data: age, gender, Child - Pugh class, etc.;
(2) Treatment information: targeted - immunotherapy combination regimen, dosage, and
cycle, etc.;
(3) Blood indicators: AFP (electrochemiluminescence method), PIVKA - II (enzyme -
linked immunosorbent assay), and liver function biochemical data (total bilirubin, albumin,
INR, etc.);

(4) Imaging evaluation information: enhanced CT/MRI reports;
(5) Survival status: your last follow - up date, etc.
III. Possible Risks and Corresponding Measures
The prospective observational study part involved in this study only collects the clinical
data of subjects, without the need to collect additional biological samples, and does not
interfere with the clinical diagnosis and treatment process, which will not have an
adverse impact on the health of subjects. Therefore, there are no research - related
adverse events involved.
IV. Expected Benefits
You may not directly benefit from this study. However, the data you provide will provide
useful information for the research of this disease, help researchers further understand
the pathogenesis of the disease and further explore the treatment plan related to the
disease, and may ultimately bring benefits to your future diagnosis and treatment and to
patients with the same disease.
V. Alternative Treatments
This study is a prospective observational study, only collecting the clinical data of
subjects, so it does not involve treatment.
VI. Research Costs
All inspection and evaluation items in this study are routine clinical inspection and
evaluation items, so the relevant costs need to be borne by you yourself. Therefore,
participating in this study will not additionally increase your routine medical treatment
costs.
In addition, this study does not provide subsidies.
VII. Compensation and Handling of Injuries
In case of damage, our research team will provide you with timely treatment. If, as judged
by the researcher, the damage is related to this study, this study will bear the
corresponding treatment costs, compensation.
VIII. Confidentiality
If you decide to participate in this study, your participation in the trial and your personal
information and related materials in the trial are confidential. Your research - related
materials will be identified by research number digits instead of your name. Information
that can identify your identity will not be disclosed to members outside the research
group unless your permission is obtained. All research members are required to keep
your identity and information confidential. Your files will be kept in a locked file cabinet
and can only be accessed by researchers. To ensure that the research is carried out in
accordance with regulations, if necessary, members of government management
departments or ethics review committees can access your personal information in the
research unit in accordance with regulations.
When the results of this study are published, no personal information of yours will be
disclosed.
IX. Voluntariness
You can choose not to participate in this study, or you can notify the researcher at any

time to request to withdraw from the study. Your data will not be included in the research
results, and your medical treatment and rights will not be affected.
If you need other treatments, or you do not comply with the research plan, or if research -
related injuries occur, or for any other reasons, the research physician can terminate your
continued participation in this study.
X. Subject's Obligations
As a subject, you have the following responsibilities: truthfully provide the true
information about your own medical history and current physical condition; inform the
research doctor of any discomfort you experience during this study; tell the research
doctor whether you have participated in other studies recently or are currently
participating in other studies.
XI. Contact Information
You can learn about the information and research progress related to this study at any
time. If you have questions related to this study, or if you experience any discomfort or
injury during the research process, you can contact the research personnel at any time
(Dr. Xu Junjie, 13656688716, 4th Floor, Building 7, Sir Run Run Shaw Hospital, Zhejiang
University School of Medicine, 3 Qingchun East Road, Hangzhou, Zhejiang).
If you have any questions about the rights of a subject participating in the research,
please contact the Ethics Committee of Sir Run Run Shaw Hospital, Zhejiang University
School of Medicine (0571 - 86006811).
Informed Consent Form - Signature Page
I have read this informed consent form.
I had the opportunity to ask questions and all questions have been answered.
I understand that participation in this study is voluntary.
I can choose not to participate in this study, or withdraw by notifying the researcher at
any time without being discriminated against or retaliated against, and my medical
treatment and rights will not be affected.
If I need other treatments, or I do not comply with the research plan, or if research -
related injuries occur or for any other reasons, the research physician can terminate my
continued participation in this study.
I will receive a signed copy of the “Informed Consent Form”.
Subject's
Name
(in
block
letters):
_________________
Subject's
Signature:
__________________ Contact Information: ______________________ Date: ______ Year
_______Month ______Day
If the subject is unable to read and sign the informed consent due to incapacity or other

reasons, or if the subject is a minor, the guardian will act as the agent for the informed
process and sign.
Guardian's
Name
(in
block
letters):
_____________
Guardian's
Signature:
_________________
Relationship
with
Subject:
____________________
Contact
Information: ______________________ Date: ______ Year _______Month ______Day
If the subject is unable to read the informed consent form (such as an illiterate subject), a
witness will witness the informed process and sign.
Witness's
Name
(in
block
letters):
_____________
Witness's
Signature:
_________________ Contact Information: ______________________ Date: ______ Year
_______Month ______Day
I have accurately informed the subject of this document, he/she has accurately read this
informed consent form, and it is proved that the subject had the opportunity to ask
questions. I prove that he/she voluntarily consented.
Researcher's
Name
(in
block
letters):
_______________
Researcher's
Signature:
_____________________ Contact Information: _______________________ Date: ______
Year ______Month ______Day