The Cochin-Pasteur

Participant in a trial

FORM FOR A HEALTHY VOLUNTEER WISHING TO TAKE PART IN A CIC 1417 STUDY

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I, the undersigned,
Certifies having read the information sheet on the Computerized File of Healthy Volunteers from CIC 1417
Allow that my name and all the data relative to me on the form « Healthy volunteer wishing to participate in a study », as well as on one of an eventual participation to research appear in an informatized file of the CIC 1417. - That the CIC 1417 staff contacts me.
Do not allow, that my name and relative data appear in the informatized file of the CIC 1417, that my administrative data collected in the form could be used internally by the CIC1417 and that I could be solicited by the CIC 1417.

The collected information is subject to an informatic treatment designed for the wishing-to-participate-in-a-study volunteers file, implying a human person. The data is only destined to the medical and administrative professionals of the CIC 1417. In accordance with the law relative to « information technology and civil liberties » of the 6th of January 1978, modified by the law no 2018-493 of the 20th of June 2018 relative to the protection of personal data. You benefit from the right to access to the data concerning  you and which is processed by the CIC 1417, to demand its correction, its update, its lock or delete and to complete it ; these rights can be applied through the treatment manager (). If the data has not been erased after your demand, you can seize the National Commission for Informatic technology and Civil Liberties (commission coordinates: refer to the CNIL web site).