Informed Consent Form For Adults
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ScribdTranslationsInformed Consent Form For Adults
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ScribdTranslationsINFORMED CONSENT FORM
ASSIGNED TO AN ADULT PARTICIPANT IN A RESEARCH PROJECT
Research Project Title:………………………………………………………………………………….
……………………………………
Principal Investigator:………………………………………………………………………………...............
I have acknowledged the newsletter. I declare that I have received explanations about the project and
to have received answers to my questions. I had the necessary time to make a decision.
I have been informed, orally and in writing, of the project's objectives, its data collection methods
data and their use as well as the terms of my participation in the project.
I have also been informed:
1- of the way researchers will ensure the confidentiality of data concerning methus
that names of the people who are responsible.
2- of my right, as a voluntary participant in this study, to withdraw at any time if I
the judge necessary without causing me any harm.
3- of my right to contact, if I have questions about the project, the Principal Investigator of the project
first name and last name
I have the assurance that the statements collected during this interview will be treated confidentially and
anonymous.
I, the undersigned:
Nom………………………………………………………First name:…………………………………………
I agree to participate in this research project under the conditions stated therein.
I can withdraw from this project at any time, without giving reasons, by notifying my
decision by the Principal Investigator or their designated representative.
I have also been informed that my participation in this project may be interrupted without my prior consent, and
in certain cases as defined in the newsletter.
I will keep a copy of the newsletter and the duly completed consent form and
signed by myself and by the Principal Investigator.
For my data / samples collected:
I authorize their transfer within the scope of the present project to another structure/another laboratory. :
In Tunisia Yes No
Abroad: Yes No
I request their destruction at the end of this project: Yes No
I authorize their retention after the closure of the project for the purpose of reuse:
for projects focusing solely on the same theme (to indicate them): Yes No
……………………………………………………………………………………………………………………
or for other research projects: Yes No
I understand that any reuse or transfer of my samples/data will only take place after notice.
favorable opinion from an Ethics Committee.
Signature :……………………………………………………Date…………………………………………
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To be completed by the witness*: not mandatory
I, the undersigned:
name……………………………………………………First Name…………………………………………
Witness of the maintenance of participant…………………… with the investigator
principal………………………………
I certify that the research participant has received explanations regarding the elements contained in the
information letter and in the consent form, that he received answers to the questions he has
asked and that he remains free to terminate his participation, and this, without prejudice.
Witness in his capacity as:
Parent of the participant: Yes None
If yes, please specify the relationship:
Others: Specify the quality:…………………… ……………………………………………….
Signature :………………………………………............... Date………………………………………….
To be completed by the Principal Investigator of the project or by their designated representative:
I, the undersigned:
Name:…………………………………………………… First name:……………………………………………
I explained to the research participant the elements contained in the information letter and in the
consent form and I answered the questions he asked. He was informed of the provisions.
related to his participation and freely gave his consent after a sufficient reflection period to
participate in this research.
I commit, along with the research team, to adhere to what has been agreed upon in the newsletter and in the
consent form. I also commit to handing a signed copy to the participant and the Committee
Biomedical Ethics of the IPT.
Coordinates:……………………………………………E-mail……………………………………………
Signature:…………………………………………………Date………………………………………………
Note: The witness must not be part of the research team or the medical and paramedical staff.
engaged in the research project
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