Syndrome) in Border Collies. This test is now available for all dogs regardless of whether

they are close relatives of TNS cases or not. The test will determine if an animal has inherited

the one copy of the chromosome carrying the TNS mutation (TNS carriers), or two copies

(TNS affected animals) or none (clear of TNS). This sample will be tested for the presence of

the TNS mutation as soon as the test is developed. The lab personnel or their employers will

not be responsible for any loss or damages that may arise in any way from the testing or the

use of the test result however the loss or damage may arise, including negligence. We use all

reasonable efforts to ensure that the results reported for each sample submitted are correct.

Pedigree information must be supplied with the sample. The sample may be tested by DNA

profiling to check pedigree information at a future date. DNA may be stored from the sample

so that the results can be retested a later date.

• I agree to have the sample from

Microchip number

Registration number

Sample label (if different from above) or Call Name

• I am the owner of the animal sampled (or have permission from the owner to submit the

sample for testing).

• I declare that the sample is definitely from the animal named

Your name Date

Your Signature Signature of witness

Address for notification of results.

email Phone

Declaration by witness of identification

I confirm that the sample labelled as indicated above is from the animal claimed as identified

by me by microchip number/ tatoo / other (please specify)

(circle one)

Name Signature

Position (eg vet, Club Cmtee Member)

Registered Name:__________________________________ Date of Birth:__________

Registration No.:__________________ Microchip No.:____________________

Sex:_______

Paternal Grandsire:__________________________________

Sire:__________________________________ Reg No:__________________

Paternal Grandam:___________________________________

Maternal Grandsire:__________________________________

Dam:__________________________________ Reg No:___________________

Maternal Grandam:___________________________________

Permission to publish is totally optional. Your choice will not affect the outcome of the

results or the speed at which the samples are processed, or your notification of results.

Signature Date

Alan Wilton

School of Biotechnology

University of NSW

NSW 2052

Dr Alan Wilton

Biotechnology, Room 217,

Biological Sciences Building (D26)

Chancellor's Walk

University of NSW

Gate 11, Botany St

Randwick NSW 2031

CONSENT FORM FOR USE OF DOG

DNA SAMPLE IN RESEARCH

ALAN WILTON

Senior Lecturer

School of Biotechnology and Biomolecular Sciences

Dr Wilton at the University of NSW is collecting blood and buccal samples from dogs for the

purposes of identification of genetic diseases in dogs. Development of DNA based tests for

carriers of disease genes will allow breeding from lines known to carry the disease gene and

then selection of disease-free progeny for future breeding without passing on the disease gene.

DNA will be extracted from the samples and stored at UNSW. The major diseases under

study are ceroid lipofuscinosis (CL), collie eye anomaly (CEA) and Trapped Neutrophil

Syndrome (TNS). The samples may be used in the study of other diseases if the research is

extended in the future unless specific instructions are given to the contrary. All samples will

be coded on arrival and in all subsequent work will only be identified by the codes. Further

information about this research can be obtained by contacting Dr Wilton (see footer for

contact details)

We cannot and do not guarantee or promise that you will receive any benefits from this study.

Any information that is obtained in connection with this study and that can be identified with

the sample will remain confidential, except where required by law or with your permission.

We plan to discuss/publish information obtained in the study only in the form of group data,

where no identification of the individual is possible. Individual disease test results will be

provided to you when available. They will not be released without your permission.

If you agree to submitting a sample for this research under these conditions please fill in and

sign the statement below and return it with the sample.

I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(name)

of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(address)

agree to the use of the sample from

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(name of dog)

to be used in the research into genetic diseases in dogs as set out above.

I do not agree/ also agree* to the sample being used in studies other than CL, CEA and TNS.

(* delete one)

I declare that I am the owner of the dog or have authority from the owner to make this

declaration on their behalf.

Signature Date

Complaints concerning this research project may be directed to the Ethics Secretariat,

University of New South Wales, Sydney 2052, Australia (phone (02) 9385 4234,

fax (02) 9385 6648, e-mail ethics.sec@unsw.edu.au). Any complaint that you make will be

treated in confidence and investigated, and you will be informed of the outcome.

If at any time you wish to withdraw the sample from the study you are entitled to do so

without preducing your future relations with UNSW. To withdraw from the study fill in the

form below and sent it in.

(Keep a copy of this form and if you wish to remove the sample from the study fill in this part

of the form and return it.)

I hereby wish to WITHDRAW my consent to participate in the research on genetic diseases in

dogs by Dr Wilton and understand that such withdrawal WILL NOT jeopardise any treatment

by or my relationship with the University of New South Wales.

__________________________ ________________________

Signature Date

__________________________ ________________________

Please PRINT name Sample Name

The Revocation of Consent should be forwarded to:

Dr Alan Wilton

School of Biotechnology and Biomolecular Sciences

University of New South Wales

SYDNEY NSW 2052