I will not participate in the research study, and I revoke my authorization to permit the researchers to collect and use any more information about me. I understand that all data that have already been collected for study purposes may be used or disclosed for the reasons agreed to when the consent form was signed. I understand and agree that in certain circumstances the researchers may need to use my information even though I have revoked my authorization, for example, to let me know about any safety concerns, to make any required reports to governmental regulatory agencies, or to ensure the research was conducted properly.

I will not actively participate in the research study any more, but the researchers may continue to collect and use information from my medical record as needed for the research study, but only for the reasons discussed in the consent form that I signed.

I understand that the researchers will respond to this letter by letting me know that they have received it.

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