Please enter the name of the faculty and the institute/department.

Please enter the name of the applicant or project manager.

Contact person for any questions:

Please enter the name of the contact person.

Phone: Please provide the phone number of the contact person.

Declaration of Consent

Title of the study: Please provide the title of the study.

I (name of the participant in block capitals)

__________________________________________________________________________________

have been informed Please select the form of information. about the study and the test procedure. I agree to Please outline what the undersigned agrees to..

Any questions I might have had were answered by

Mr. / Ms. _______________________ in full and to my satisfaction.

Select an option - Please note: Select either the option "Coding List" or "Personal Code Word", and delete the option that has not been selected from the document.:

["Coding list"]

I hereby agree to the collection and processing of the following data: Please specify which data are being collected and, in case of health data, list them precisely. Data will be recorded and evaluated under a pseudonym at Please state the name of the research institute., using a number and without giving my name. The connection between my name and this number can be taken from a coding list on paper. This coding list is only accessible to the researcher and the project manager; they are the only ones who will be able to associate collected data with my name. After completion of Please select an option., but on Please select the date. at the latest, the coding list will be deleted. My data will then be anonymized. This means that it is no longer possible for anyone to associate the collected data with my name. I am aware that I am entitled to withdraw my consent to the data storage without prejudice. I have been informed that I can request deletion of all my data at any time. However, if the coding list has already been deleted, my data record can no longer be identified and therefore not be deleted. My data will then be anonymized. I agree that my anonymized data may be used for research purposes and remain stored for a minimum period of 10 years.

[including additional agreement for future contacts regarding this study]

I hereby consent to the coding list being stored for an additional period of five years and to being contacted for follow-up studies if this study or follow-up studies are continued. I am aware that I am entitled to withdraw my consent to the data storage without prejudice. I have been informed that I can request deletion of all my data at any time. However, if the coding list has already been deleted, my data record can no longer be identified and therefore not be deleted.

□ YES	□ NO

or

["Personal code word"]

I hereby agree to the collection and processing of the following data: Please specify which data are being collected and, in case of health data, list them precisely. Data will be recorded and evaluated in an anonymized manner at Please state the name of the research institute., i.e. using a personal code word I have created myself and that only I know. This means that it is impossible for anyone to associate my data with my name. The sheet of paper on which I have created this code word is in my possession. I am aware that I am entitled to withdraw my consent to the data storage without prejudice. I have been informed that I can request deletion of all my data at any time. I agree that my anonymized data may be used for research purposes and remain stored for a minimum period of 10 years.

I have been informed that my name, my address and my phone number are only on this declaration of consent.

[Feedback of results]

I would like to learn more about the basic results of the study and to be sent relevant information.

□ YES	□ NO

Place, date & signature of the participant:	Name of the participant (in block letters):

_____________________________________	_____________________________________

Place, date & signature of the contact person:	Please enter the contact name.:

_____________________________________	_____________________________________

Bank details in case of payment of the compensation by bank transfer

Account holder:	____________________________________________________________

IBAN:	__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

BIC:	__ __ __ __ __ __ __ __ __ __ __

Bank, branch office:	____________________________________________________________

In case of any queries I may contact the following persons:

Contact person:
First name and family name of the contact person.

Please provide the contact's office address.

Please provide the contact's office phone number.

Please provide the contact person's email address.

Applicant / Project manager:
First name and family name of the applicant / project manager.

Please provide the office address of the applicant / project manager.

Please provide the officice phone number of the applicant / project manager.

Please provide the email address of the applicant / project manager.