Appendix 4: Informed Consent Form representative

Research about prostate cancer follow-up care in secondary and primary health care (PROSPEC study)

I have read the information letter. I was also able to ask questions. My questions have been answered sufficiently. I have had enough time to decide whether I want to participate in the study.

I understand that participation is voluntary. I also know that I can decide at any time that I would rather not participate. Without having to provide any reason.

I give consent to collecting and using my data to answer the research question in this study as described in the information letter.

I give consent to potentially be approached for a short interview about my experiences with my follow-up and this study.

I give consent to inform the general practitioner that I am participating in this study. I give consent to requesting information from the general practitioner. 

I know that for study monitoring purposes some individuals could have access to my data. These individuals are listed in this information letter. The storage of my data will be coded

I give consent to save my data for 15 years after completion of this study.

I agree to participate in this study.

Name of subject:
Signature:							Date: __ / __ / __

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I hereby certify that I have informed the above person/persons fully about the said study.

If information becomes known during the study that could influence the consent of the legal representative, I will inform him/her of this on time.

Name of investigator (or his/her representative):
Signature:							Date: __ / __ / __

The representative will receive a complete information letter, along with a signed version of the informed consent form.