ANNEX C.2a: Prosperity4All Informed Consent Concerning Private Information

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This form will be used by all Prosperity4All investigators who record private information in the course of any Prosperity4All pilot tests involving human beings. It has to be signed by the investigator and by each participant. One copy of the signed form has to be given to the participant.

Please clearly explain to the participant how the following issues regarding privacy are handled related to the test at hand:

·         What kind of data will be recorded, stored and why?

·         Will the data be transferred?

·         Data ownership?

·         Is the data connected to other information?

·         Will the data possibly be commercially exploited?

·         Length of storage?

·         Where will the data be stored, - according to which national legislation?

·         Who will access the data?

·         Who will supervise the data protection?

Investigator

Date …...............................................................................

 

Name (in capitals) .......................................................................……….

 

Signature ....................................................................................

 

Participant

Date …................................................................................

 

Name (in capitals) ........................................................................……….

All information mentioned in the shadowed box above has been given to me. I was able to fully understand all topics, ask questions and demand further clarifications. For the moment I have no additional questions; I fully understood that I may ask for additional information anytime in the course of the test.

 

Signature ....................................................................................