[Insert Title of Research Proposal]

INFORMED CONSENT FORM

(to be completed after Participant Information Sheet has been read)

Taking Part / Please initial to confirm agreement
The purpose and details of this study have been explained to me. Iunderstand that this study is designed to further scientific knowledge andthat all procedures have been approved by the Loughborough University Ethics Approvals (Human Participants) Sub-Committee. / ------
I have read and understood the information sheet and this consent form. / ------
I have had an opportunity to ask questions about my participation. / ------
I understand that taking part in the project will involve [e.g. being photographed, interviewed and recorded (audio or video)]. / ------
I understand that taking part in the study has [……………….….…………….] as potential risk. / ------
I understand that the personal information collected will be [e.g. name, address, date of birth etc]. / ------
I understand that sensitive personal information, [add details], will be collected during this study. / ------
I understand that I am under no obligation to take part in the study, have the right to withdraw from this study at any stage for any reason, and will not be required to explain my reasons for withdrawing. / ------
Use of Information
I understand that all the personal information I provide will be processed in accordance with data protection legislation on the public task basis [amend if another basis is being used] and will be treated in strict confidence unless (under the statutory obligations of the agencies which the researchers are working with), it is judged that confidentiality will have to be breached for the safety of the participant or others or for audit by regulatory authorities. / ------
I understand that information I provide will be used for [e.g. publications, reports, web pages, research outputs, etc]. / ------
I understand that personal information collected about me that can identify me, such as my name or where I live, will not be shared beyond the study team. / ------
I agree that information I provide can be quoted anonymously in research outputs. / ------
If you want to use named quotes, add: I agree that my real name can be used for quotes. / ------
If written information is provided by the participant (e.g. diary), add: I agree to joint copyright of the [specify the data] to [name of researcher]. / ------
I give permission for the anonymised data I provide to be deposited in [name of data repository or data archive] so that it can be made publicly available for future research at the end of the project. / ------
Bodily Samples [NOTE: if both clauses are included, add: please only initial ONE of the following two statements]
I agree that the bodily samples taken during this study can be stored until [insert date] for future research in the same research theme as this project. / ------
[Or]
I agree that the bodily samples taken during this study can only be used for this study and will be disposed of within XX years [or]upon completion of the research [insert date]. / ------
Consent to Participate
I voluntarily agree to take part in this study. / ------

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Name of participant[printed]Signature Date

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Researcher[printed]Signature Date

HPSC Ref No: [to be added once study approval confirmed]