Participant Consent Form – Partial Consent (reference)
Assent Section
Has somebody explained this study to you?
Yes / No
Do you understand what this study is about?
Yes / No
Have you asked all the questions you want?
Yes / No
Have your questions been answered in a way you understand?
Yes / No
Do you understand it’s OK to stop taking part at any time?
Yes / No
Are you happy to join in?
Yes / No
Consent Section
1. I confirm that I have read the information sheet dated 15/08/23 (version 4.0) for the above study and that I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.
Please Initial
2. I understand that my child’s participation is voluntary and that I am free to withdraw my consent at any time without giving any reason and without my child’s medical care or legal rights being affected.
Please Initial
3. I agree for my child’s NHS asthma medical records to be accessed by authorised individuals from the research team, the University of Leicester (as the Sponsor), the NHS and the GP practice, where it is relevant to my child’s taking part in this research, I authorise these individuals to have access to these records.
Please Initial
4. I agree for my child’s asthma medical records to be used for this study.
Please Initial
5. I agree for my child’s asthma medical records to be used for this study, providing any data used is anonymised in any publication of results so that my child is not named or identified personally.
Please Initial
6. I agree for this consent form and personal details relating to my child to be stored securely and electronically by Helicon Health Ltd as detailed within the participant information sheet.
Please Initial
7. I agree for the research team to notify my GP and/or any other health or care professional responsible for my child’s care that my child’s asthma medical record is being used in this study.
