1. Request for Comprehensive Consent for Using Samples from Medical Examination
Haga Red Cross Hospital is making great efforts in order to provide the best possible medical treatment to each and every patient.
We are educating the medical community through medical trainings for students, junior residents and nurses, and also conducting medicaland clinical studies in order to contribute to advances in medical science.
For “Explanation” and “Consent” we use two methods as below;
1. Individual Consent
Obtain approbation orally or in written from patients after explanation individually.
2. Comprehensive Consent
Obtain approbation without process like above mentioned “Individual Consent” under the prescribed standards.
More details about above mentioned “Comprehensive Consent”. Regarding below describes matters, comprehensive consent is deemed asagreed by this document.
We appreciate your understanding and cooperation for your comprehensive consent which is needed for our medical care,education program and clinical studies.
Approbation must be done free-willed. Be assured, your care will never be disadvantaged if you do choose disapprobation.
You can withdraw your approbation anytime.
In the case of disapprobation, please ask our contact mentioned in “3.Inquiry”.

令和 4 年 3 月 17 日

2. Regarding the Use of Samples from Medical Examination for Medical Investigation
Haga Red Cross Hospital is providing the best possible medical treatment at this time. We are also conducting clinical- and basic study
in order to develop better medical care for the future patients. We need to use your samples from medical examination for that.
Thank you very much in advance for your understanding and cooperation.

Medical information and Samples from Medical Examination
Your medical information, including your disease and test samples below-mentioned, is collected when you receive a medical examination
at Haga Red Cross Hospital.
For examples;● Medical records●X-ray photography, endoscopic photography, image information such as operation movies●Physiological function testing (electrocardiogram, ultrasonography, audiometric test etc.)●test samples (blood and urine etc.)●biopsy samples for diagnosis, excised tissues and their photography.
Hereafter, they will collectively be referred to as “samples from medical examination”

令和 4 年 3 月 17 日Samples from medical examination are collected and stored after your medical examination, but they could provide important information
for medical investigation even after they are no longer needed for your own medical examination.
Haga Red Cross Hospital would like to use your samples for studies of illnesses and the development of medical care.
When we are collecting blood, urine, cells, tissues, etc., the minimum required amount is collected, but a part of the sample may remain.
Such remaining samples are valuable thing for our clinical studies.
●Person who is requested for donation of medical information and test samples
We ask for all the patients for donation of medical information and test samples. Providing samples for medical investigation is voluntary.
It must be done free-willed. If we do not receive your declaration of intention to disapprobation, it is deemed as accepted essentially.
Before using of medical information and test samples, The Ethical Committee of Haga Red cross hospital will deliberate on the content of themedical study for each case. The hospital will also do deliberate on the content of the medical study for each case for using above explained
remaining samples according to the rules of the national ethical guidelines.
●Personal information protection
Providing medical information, samples, etc. to the research does not pose any direct risk to the patients. However, in the unlikely eventthat personal information is leaked, patients may suffer disadvantages. Samples of medical examination are anonymized andHaga Red Cross Hospital makes every effort to keep the information confidential when they are being used for medical studies.
The results of medical studies may be made public through academic conferences and medical professional journals, but the hospital will neverprovide any identifying personal information.
●Intellectual property rights
Intellectual property rights such as patent rights may arise depending on the outcome of research using the medical informationand test samples provided. Please note that the right belongs to Haga Red Cross Hospital and not to the patient himself / herself.

令和 4 年 3 月 17 日

3. Inquiry
If you have any concerns or questions about this document, please feel free to make inquiries.
In the case of disapprobation or approbation withdrawal, please fill in the blanks for the “Disapprobation Form for Using Samples
for Medical Studies” or “Approbation Withdrawal Form for Using Samples for Medical Studies” and submit them at the Information Deskon the first floor of the hospital. If you do not make a request for disapprobation or approbation withdrawal, we will assume that you have agreed.
Be assured, your care will never be disadvantaged if you do choose disapprobation.
Prepared and confirmed in February, 2022

令和 4 年 3 月 17 日