HEADING : Queen's university logo as research occuring in QUB

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Consent Form
(This is a sample consent form for you to add to as appropriate for your particular project)
Title of the project:
Please initial box
1.
I confirm that I have been given and have read and understand the Information
Leaflet for the above study. I have had the opportunity to ask, and receive answers
to any questions I may have had.
[
]
2.
I understand that my participation is voluntary and that I am free to withdraw at any
time, without giving any reason.
[
]
3.
I agree to take part in the above study, inclusive of the procedures mentioned in the
Information Leaflet (please specify eg bloods, videos, questionnaires, additional tests).
[
]
4.
I understand that my participation or non-participation will not affect my
career progression, my medical care or my legal rights being affected
in anyway (use which ever [or all] if appropriate).
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]
5.
I understand all data will be treated securely as described by Data Protection
and stored appropriately as required by the University.
[
]
6.
I understand that I will not be identifiable in any data published in relation to this
project.
[
]
I agree to take part in this project
_____________________
Name of Participant
________
Date
___________________
Signature
_____________________
Name of Person taking consent
(if different from Researcher)
__________
Date
__________________
Signature
___________________
Name of Researcher
__________
Date
Name of Researcher:
Contact details of researcher:
One copy for Researcher and one copy for the subject
___________________
Signature
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