An Assistive Powered Wheelchair: Stage 2 Trial - Powered Wheelchair User Evaluation of an Obstacle Alerting System. A Non-interventional Study
Conditions: Multiple Sclerosis, Stroke, Cystic Fibrosis, Motor Neurone Disease, Craniocerebral Trauma, Guillain-Barre Syndrome
Sponsor: East Kent Hospitals University NHS Foundation Trust

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EDUCAT Stage 2 PWC Participant Consent Form - Photographic Images vs 1.1 PRS.docx 
 
29/06/2020 Page 1 of 3 
 
Project Title: EDUCAT: An Assistive Powered Wheelchair. Stage 2. Powered Wheelchair User 
Evaluation of an Obstacle Alerting System.  
 
NCT Number: NCT05292690 
 
Document Date: 29/06/2020 
 
 
 

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EDUCAT Stage 2 PWC Participant Consent Form - Photographic Images vs 1.1 PRS.docx 
 
29/06/2020 Page 2 of 3 
IRAS ID: 257062 
Site Name: 
 
Participant Identification Number for this trial: 
CONSENT TO USE IMAGES FORM 
Title of Project: EDUCAT An Assistive Powered Wheelchair – Stage 2: User Evaluation of an 
Obstacle Alerting System 
Name of Researcher: 
As part of this research study, we would like to take some photographs and/or video clips for data 
analysis and evaluation.  
 
These images will be held securely and may be retained in both paper and electronic formats, as 
part of the record of this evaluation and any associated reports, in accordance with the General 
Data Protection Regulation (GDPR 2018). 
 
This consent form limits the use of your images to the purposes that you select below.   
 
Refusal to give your consent for any of the listed purposes will not affect your participation in this 
study.   
 
You may withdraw your consent at any time, by contacting (Insert name of PI and/or local site 
researcher) - contact details below. 
 
Please add your initials into the appropriate box to indicate your choice. 
 
  
 
 
 
 
 
 
 
 
YES 
 
NO 
1. Would you be happy to consent to photographic and video images 
being taken for use within this research study? 
 
 
2. Do you want these images to be anonymised? i.e. face pixelated 
 
 
 
3. Would you be happy for these images to be used within associated 
professional reports, conference presentations and potential 
publications? 
 
 
4. Would you be happy to consent to images being used to promote this 
research study via websites and social media?  For example, the 
EDUCAT website and (insert organisational name). 
I understand that (organisational name) can have no control over the 
downloading and use of any images used on public websites. 
 
 
5. Would you be happy to consent to images being used for promotional 
purposes by the EDUCAT partner institutions? 
 
 
6. I have read the above statements and I consent to my images being 
used for the purposes identified as indicated in the above list. 
 
 
 
 
 

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EDUCAT Stage 2 PWC Participant Consent Form - Photographic Images vs 1.1 PRS.docx 
 
29/06/2020 Page 3 of 3 
 
 
 
 
 
 
 
 
 
 
 
 
 
Name of Participant 
 
Date 
 
 
 
Signature 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Name of Person 
 
Date 
 
 
 
Signature 
taking consent 
 
 
Insert local site contact details – Name of PI and/or researcher & contact details 
 
NB. Original copy for site filenotes and one copy for participant.