ࡱ> joi~{ Ibjbj 4>ff 58\6LsY&l"d"$"XXXXXXX$\O_Y#""^##Yv-Y&&&#jX&#X&&N8S`Aar#P&XCY0sYPB_$_L8S^S8_S##&#####YY$J###sY####_#########X T: APPENDIX [INSERT REFERENCE] INFORMED CONSENT FORM in relation to [Insert title of the Research Project as stated on page 1 of the information sheet] I have read the information sheet and I have been informed by .. orally and in writing (see pages 2 and following) about the nature and the potential consequences and risks of the above-mentioned research project (the Research Project), and I have had sufficient opportunity to ask any questions. I understand that my data will be collected and used in connection with this Research Project and to enable publication of the research results. I have been informed that I am entitled to withdraw my consent to participate in the Research Project at any time without giving a reason and without negative consequences to myself. Furthermore, I may object to further processing of my personal data and/or samples or request that these be deleted. I may do so by contacting XXXX. Please tick the appropriate boxes in the table below [ADAPT THE QUESTIONS ACCORDING TO YOUR SPECIFIC RESEARCH PROJECT]: IF CONSENT IS CHOSEN AS THE LEGAL BASIS FOR PROCESSING: I consent to the collection and use of my personal data in relation to the Research ProjectYesNoI agree to the data I provide being archived at [INSERT LOCATION] and being used in [pseudonymised] [anonymised] form for other research in the area of [INSERT RESEARCH AREA] beyond the Research ProjectYesNoI consent to my interviews being recorded in audio and video format for the purposes of the Research ProjectYesOnly if my identity is not disclosedNoI consent to my personal data, as described in the information sheet, being processed for the purposes of [SPECIFY RESEARCH OUTPUTS] YesOnly if my identity is not disclosedNoI am happy to be contacted after this Research Project to ask whether I would be interested in taking part in a follow-up studyYesNoIF APPLICABLE: I consent to my (pseudonymised) data being transferred to [ADD COUNTRY]and I consent to the transfer. I am aware that the laws of [ADD COUNTRY] may not offer the same level of privacy protection as in the European Union.YesNo I voluntarily agree to take part in this Research Project. PARTICIPANT Last name: ______________________ First name:________________________ Date of birth:______________________ Place & date: _______________________________________ Signature of the participant:______________________________________________ Signature of the legal representative:_______________________________________ RESEARCHER I have informed the above-mentioned participant orally and in writing (see pages 1 and following) about the nature and the potential consequences and risks of the Research Project, and I have given the participant the opportunity to ask any questions. In addition, the participant has received a copy of the information sheet(s) and of this consent form. 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