Data Use Consent Form for Biomedical Research

Participant Information

Full Name Date of Birth Email Address

Research Information

Study Title Institution Principal Investigator

Data Use and Consent

This research will collect, store, and use your data for biomedical research purposes as described below:

• Collection and analysis of biological data
• Storage of data in secure databases
• Possible publication of research results without personal identifiers

I consent to the collection, storage, and use of my data for the purposes described above.

Withdrawal and Contact

You may withdraw your consent at any time without any penalty. For more information, contact:

Signature

Participant Signature Date