To everyone who have a health checkup
Ver.2 2022
Request for your consent to storage and future use of your unused residual samples(Explanation for general consent)
Upon your consent, we would like to store your unused residual urine and blood samples (called humansamples) after routine examination. We will use these samples only for basic and clinical researches that
contribute to the development of medical checkup system, public health activity and medical science.
We always do our best for daily health checkup. In addition, it is also our mission to contribute to theprogress of medical checkup system, public health activity and medical science. Human samples will bevery useful for any researches in our division to complete our mission.
Therefore, we are seeking your understanding and cooperation for our proposal.

1. Human samples for our researches are derived from unused serum and urine (not including DNA
and any genetic information) after routine examination. Thus, another collection of your blood or urine
is not required.
2. It is completely your discretion to agree or decline this proposal. There is no disadvantage against
our health support for you, even if you do not present agreement. You have the right to cancel yourprevious agreement anytime. We accept your cancellation via written withdrawal form. After yourwithdrawal, your stored samples are discarded in compliance with the administrative policy and rules
for infectious medical waste of Osaka University Hospital. However, we still have the right to use thedata for your routine medical checkup obtained from your sample.
3. We propose every research plan to Osaka University Ethical Review Board. All researches arecarried out in conformance with the approval of this committee in advance.
4. Human samples are stored securely in Health Care Division, Health and Counseling Center.
Retention period will not be limited. These samples are anonymized not to identify individual name.
Each sample is given a unique code of letters and numbers linked to the donor, but the linkageinformation table is securely locked up in our division and will be completely masked. Thus we cansearch and inform your own data upon your request, or discard your residual samples.
5. Some results derived from future researches will be published in academic conferences and journals,
but any individual information is completely masked and will never be open to public or any thirdparty. Your private information including name, address, and birthday is completely protected.
6. Some of these researches may bring intellectual property rights. These rights belong to Osaka
University. Researches will not affect our health support for you. You have the right to be informed ofyour own results upon your request, which is the only advantage of your participation. Of course, there
is no disadvantage against your participation. We do not pay a fee in token of your gratitude. Of course,
there is no disadvantage against your participation. You don’t have to pay any examination fee.
If you want more information, please consult a doctor in Health Care Division.
Contact name: KUDO Takashi in charge of human sample’s storage.
Health Care Division, Health and Counseling Center, 1-17 Machikaneyama-cho, Toyonaka, Japan. Tel: 06-6850-6038

Many diseases have not been overcome yet, despite recent advances of medical science.
Thus further medical researches should be conducted. In the medical research, samples from healthy subjects are very
important to compare with the samples from sick subjects. We commit protection of privacy, individual dignity, andhuman-rights of you. Thank you very much for your consideration and your valuable cooperation to complete ourmission of contributing to the progress of medical checkup system, public health activity and medical science.

Director of Health and Counseling Center, Professor KUDO Takashi
Division director, Professor NAGATOMO Izumi