Clinical trial: NCT05252780
Section: Participant's Rights
Subsections: Informed Consent|Informed Consent|Informed Consent|Informed Consent|Informed Consent|Informed Consent|Informed Consent Control Group|Informed Consent|Informed Consent|Informed Consent

On behalf of the Universidad de los Andes, we extend a cordial invitation to participate in the study: "Mybody, my rhythm, my voice: Promotion of physical activity in breast cancer survivors in Colombia". If you decide to participate, your participation in the study will consist of attending rumba sessions (musicalized physical activity) and allowing the collection of data that will be detailed in this document.  
This is a study coordinated by Dr. Olga Lucía Sarmiento and her group of researchers; It has the support of the Faculty of Medicine of the Universidad de los Andes, in partnership with researchers from the Manuela Beltrán University, Stanford University, the League Against Cancer, the Ministry of Health, the District Institute of Recreation and Sports of Bogotá and the SIMMON Foundation. This document explains the different aspects of the research study: its purpose, the procedures to be performed, the risks of the procedures, and the potential benefits. Once you know what the study is about, you will be asked if you wish to participate, and if so, you will be asked to sign this written authorization.  
Purpose of the study: The purpose of this study is to see what the motivations and barriers are to attending physical activity sessions and what changes in physical and mental health occur as a result of the practice of physical activity. It also identifies barriers to ensuring the permanence of a program to promote physical activity in breast cancer survivors.  
Study Procedures: If you choose to participate, an appointment will be scheduled with you to assess your current health status by taking body composition and physical activity data. These measurements, which will be described below, will be carried out in the same institution where the physical activity sessions will be carried out.  
Body composition is assessed by a bio-impedanceometry test. This test is performed on special scales that have metal plates that conduct a type of weak electric current that passes through the entire body. Thanks to this current, these scales can calculate the amount of muscle, fat, and water in the body.  
To measure physical activity, you will be asked to use a portable motion meter (accelerometer); which is a device that gives objectively the amount of movement you perform during the day. The use of this meter does not alter your daily activities or generate discomfort or pain. The monitoring with this device will last twenty-four (24) hours during seven (7) consecutive days. To measure your functional capacity, we will perform a test called a 6-minute walk, which consists of measuring the maximum distance you can walk for 6 minutes without stopping. This measurement will be performed twice (during the first measurement, and 8 weeks later). This test will be carried out in a flat space, delimited by cones and without any obstacles. In addition to this, we will use a device called Polar (similar to a watch), which will be placed on your wrist, to measure your heart rate during the test.  
In this first measurement, you will also be asked to answer an initial survey on sociodemographic data, quality of life, anxiety, perception of fatigue and other health indicators. Likewise, you will be invited to a meeting with the other participants to discuss the main motivations for the practice of physical activity.  
After this, you will be invited to participate for 8 weeks in physical activity classes offered three times a week and led by trained staff. Some sessions will be accompanied by workshops of manual arts and healthy habits to be carried out in the same space of the physical activity sessions. Additionally, psychosocial support will be provided to strengthen behavioral change, through a pedagogical primer. Once the intervention is finished, measurements similar to the initial one will be made again to determine if you had any change in your health condition as an effect of the rumba classes. Finally, a meeting will be held to learn about your experience in physical activity classes; you will have an audio record of those meetings. Your family members can also participate in the directed physical activity classes, workshops, and the meeting with the research group.  
Study Risks: During physical activity sessions there are risks of falls and injuries. To minimize these risks, physical activity classes have been adapted to their needs and limitations given by their underlying pathology. There will be the permanent accompaniment of personnel trained in life support during the physical activity classes, who in case you require urgent medical attention, will immediately call the emergency service of the Health Institution, will provide you with the necessary life support measures while you are referred to the attention by the emergency doctor. To be included in this study you must have affiliation to the health system and carry your membership card during all physical activity sessions.  
Benefits of the study: This study seeks to contribute to the quality of life of women survivors of breast cancer, motivating them to practice physical activity through rumba sessions of an approximate duration of one hour each. The sessions have been designed and will be offered by experts who have knowledge of the limitations that breast cancer patients present as a result of chemotherapy, radiotherapy or surgery treatment.  
Through your participation in this study, we want to make you aware of the multiple benefits that result from the habitual practice of physical activity. Just as we hope to understand and make visible your perceptions and your family's in the face of the establishment of a program of direct physical activity linked to the care of your health. Refreshments will be delivered in each of the classes or workshops and other gifts will also be given as a thank you for your participation.

| Date: ___________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | Place: _______________________________________ Yes   | No   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------|------|
| I authorize audio recording and use for research purposes I authorize audio transcription and use for knowledge dissemination I authorize the taking of photos and their use for research purposes I authorize the taking of photos and their use for dissemination of knowledge Signatures: ______________________________________________________________________________ Name Signature or Fingerprint* Date CC ______________________________________________________________________________ Residence address City Phone  ______________________________________________________________________________ Witness 1 CC Date ______________________________________________________________________________ Witness2 CC Date ______________________________________________________________________________ Who applies the informed consent CC Date |                                                      |      |  
Project title: My body, my rhythm, my voice. **Promotion of physical activity in breast**  
  
cancer survivors in Colombia.  
Consent: By means of this consent I _____________________________________________ declare that the objective  
  
of this project has been clarified to me. I also declare that I have been offered the opportunity to resolve all my doubts regarding the study. I declare that I do not have any heart disease diagnosed so far. In addition, I place on record that I read and understood the contents of this document.  
*The fingerprint of the participants is requested in case they do not know how to read and / or write

Consent: By means of this consent I _____________________________________________ declare that the  
  
objective of this project has been clarified to me. I also declare that I have been offered the opportunity to resolve all my doubts regarding the study. I declare that I do not have any heart disease diagnosed so far. In addition, I place on record that I read and understood the contents of this document.  
| Date: ___________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | Place: _______________________________________ Yes   | No   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------|------|
| I authorize audio recording and use for research purposes I authorize audio transcription and use for knowledge dissemination I authorize the taking of photos and their use for research purposes I authorize the taking of photos and their use for dissemination of knowledge Signatures: ______________________________________________________________________________ Name Signature or Fingerprint* Date CC ______________________________________________________________________________ Residence address City Phone  ______________________________________________________________________________ Witness 1 CC Date ______________________________________________________________________________ Witness2 CC Date ______________________________________________________________________________ Who applies the informed consent CC Date |                                                      |      |  
*The fingerprint of the participants is requested in case they do not know how to read and / or write

On behalf of the Universidad de los Andes, we extend a cordial invitation to participate in the study: "Mybody, my rhythm, my voice: Promotion of physical activity in breast cancer survivors in Colombia". If you decide to participate, your participation in the study will consist of attending rumba sessions (musicalized physical activity) and allowing the collection of data that will be detailed in this document.  
This is a study coordinated by Dr. Olga Lucía Sarmiento and her group of researchers; It has the support of the Faculty of Medicine of the Universidad de los Andes, in partnership with researchers from the Manuela Beltrán University, Stanford University, the League Against Cancer, the Ministry of Health, the District Institute of Recreation and Sports of Bogotá and the SIMMON Foundation. This document explains the different aspects of the research study: its purpose, the procedures to be performed, the risks of the procedures, and the potential benefits. Once you know what the study is about, you will be asked if you wish to participate, and if so, you will be asked to sign this written authorization.  
Purpose of the study: The purpose of this study is to see what the motivations and barriers are to attending physical activity sessions and what changes in physical and mental health occur as a result of the practice of physical activity. It also identifies barriers to ensuring the permanence of a program to promote physical activity in breast cancer survivors.  
Study Procedures: If you choose to participate, an appointment will be scheduled with you to assess your current health status by taking body composition and physical activity data. These measurements, which will be described below, will be carried out in the same institution where the physical activity sessions will be carried out.  
Body composition is assessed by a bio-impedanceometry test. This test is performed on special scales that have metal plates that conduct a type of weak electric current that passes through the entire body. Thanks to this current, these scales can calculate the amount of muscle, fat, and water in the body.  
To measure physical activity, you will be asked to use a portable motion meter (accelerometer); which is a device that gives objectively the amount of movement you perform during the day. The use of this meter does not alter your daily activities or generate discomfort or pain. The monitoring with this device will last twenty-four (24) hours during seven (7) consecutive days. To measure your functional capacity, we will perform a test called a 6-minute walk, which consists of measuring the maximum distance you can walk for 6 minutes without stopping. This measurement will be performed twice (during the first measurement, and 8 weeks later). This test will be carried out in a flat space, delimited by cones and without any obstacles. In addition to this, we will use a device called Polar (similar to a watch), which will be placed on your wrist, to measure your heart rate during the test.  
In this first measurement, you will also be asked to answer an initial survey on sociodemographic data, quality of life, anxiety, perception of fatigue and other health indicators. Likewise, you will be invited to a meeting with the other participants to discuss the main motivations for the practice of physical activity.  
After this, you will be invited to participate for 8 weeks in physical activity classes offered three times a week and led by trained staff. Some sessions will be accompanied by workshops of manual arts and healthy habits to be carried out in the same space of the physical activity sessions. Additionally, psychosocial support will be provided to strengthen behavioral change, through a pedagogical primer. Once the intervention is finished, measurements similar to the initial one will be made again to determine if you had any change in your health condition as an effect of the rumba classes. Finally, a meeting will be held to learn about your experience in physical activity classes; you will have an audio record of those meetings. Your family members can also participate in the directed physical activity classes, workshops, and the meeting with the research group.  
Study Risks: During physical activity sessions there are risks of falls and injuries. To minimize these risks, physical activity classes have been adapted to their needs and limitations given by their underlying pathology. There will be the permanent accompaniment of personnel trained in life support during the physical activity classes, who in case you require urgent medical attention, will immediately call the emergency service of the Health Institution, will provide you with the necessary life support measures while you are referred to the attention by the emergency doctor. To be included in this study you must have affiliation to the health system and carry your membership card during all physical activity sessions.  
Benefits of the study: This study seeks to contribute to the quality of life of women survivors of breast cancer, motivating them to practice physical activity through rumba sessions of an approximate duration of one hour each. The sessions have been designed and will be offered by experts who have knowledge of the limitations that breast cancer patients present as a result of chemotherapy, radiotherapy or surgery treatment.  
Through your participation in this study, we want to make you aware of the multiple benefits that result from the habitual practice of physical activity. Just as we hope to understand and make visible your perceptions and your family's in the face of the establishment of a program of direct physical activity linked to the care of your health. Refreshments will be delivered in each of the classes or workshops and other gifts will also be given as a thank you for your participation.

| Date: ___________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | Place: _______________________________________ Yes   | No   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------|------|
| I authorize audio recording and use for research purposes I authorize audio transcription and use for knowledge dissemination I authorize the taking of photos and their use for research purposes I authorize the taking of photos and their use for dissemination of knowledge Signatures: ______________________________________________________________________________ Name Signature or Fingerprint* Date CC ______________________________________________________________________________ Residence address City Phone  ______________________________________________________________________________ Witness 1 CC Date ______________________________________________________________________________ Witness2 CC Date ______________________________________________________________________________ Who applies the informed consent CC Date |                                                      |      |  
Project title: My body, my rhythm, my voice. **Promotion of physical activity in breast**  
  
cancer survivors in Colombia.  
Consent: By means of this consent I _____________________________________________ declare that the objective  
  
of this project has been clarified to me. I also declare that I have been offered the opportunity to resolve all my doubts regarding the study. I declare that I do not have any heart disease diagnosed so far. In addition, I place on record that I read and understood the contents of this document.  
*The fingerprint of the participants is requested in case they do not know how to read and / or write

Consent: By means of this consent I _____________________________________________ declare that the  
  
objective of this project has been clarified to me. I also declare that I have been offered the opportunity to resolve all my doubts regarding the study. I declare that I do not have any heart disease diagnosed so far. In addition, I place on record that I read and understood the contents of this document.  
| Date: ___________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | Place: _______________________________________ Yes   | No   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------|------|
| I authorize audio recording and use for research purposes I authorize audio transcription and use for knowledge dissemination I authorize the taking of photos and their use for research purposes I authorize the taking of photos and their use for dissemination of knowledge Signatures: ______________________________________________________________________________ Name Signature or Fingerprint* Date CC ______________________________________________________________________________ Residence address City Phone  ______________________________________________________________________________ Witness 1 CC Date ______________________________________________________________________________ Witness2 CC Date ______________________________________________________________________________ Who applies the informed consent CC Date |                                                      |      |  
*The fingerprint of the participants is requested in case they do not know how to read and / or write

On behalf of the Universidad de los Andes, we extend a cordial invitation to participate in the study: "Mybody, my rhythm, my voice: Promotion of physical activity in breast cancer survivors in Colombia". If you decide to participate, your participation will consist of allowing the collection of data that will be detailed in this document and subsequently attend sessions of musicalized physical activity.  
This is a study coordinated by Dr. Olga Lucía Sarmiento and her group of researchers; It has the support of the Faculty of Medicine of the Universidad de los Andes, in partnership with researchers from the Manuela Beltrán University, Stanford University, the League Against Cancer, the Ministry of Health, the District Institute of Recreation and Sports of Bogotá and the SIMMON Foundation.  
This document explains the different aspects of the research study: its purpose, the procedures to be performed, the risks of the procedures, and the potential benefits. Once you know what the study is about, you will be asked if you wish to participate, and if so, you will be asked to sign this written authorization.  
Purpose of the study: The purpose of this study is to see what the motivations and barriers are to attending physical activity sessions, and what changes in physical and mental health occur as a result of the practice of physical activity.  
Also, the identification of factors to ensure the permanence of a program of promotion of physical activity in breast cancer survivors.  
Study Procedures: If you choose to participate, an appointment will be scheduled with you to assess your current health status by taking body composition and physical activity data. These measurements, which will be described below, will be carried out in the same institution that has invited you to participate in the study. Body composition is assessed by a bio-impedanceometry test. This test is performed on special scales that have metal plates that conduct a type of weak electric current that passes through the entire body. Thanks to this current, these scales can calculate the amount of muscle, fat, and water in the body.  
To measure physical activity, you will be asked to use a portable motion meter (accelerometer); which is a device that gives objectively the amount of movement you perform during the day. The use of this meter does not alter your daily activities or generate discomfort or pain. The monitoring with this device will last twenty-four (24) hours during seven (7) consecutive days.  
To measure your functional capacity, we will perform a test called a 6-minute walk, which consists of measuring the maximum distance you can walk for 6 minutes without stopping. This measurement will be performed twice (during the first measurement, and 8 weeks later). This test will be carried out in a flat space, delimited by cones and without any obstacles. In addition to this, we will use a device called Polar (similar to a watch), which will be placed on your wrist, to measure your heart rate during the test.  
In this first measurement, you will also be asked to answer an initial survey on sociodemographic data, quality of life, anxiety, perception of fatigue and other health indicators. Likewise, you will be invited to a meeting with the other participants to discuss the main motivations for the practice of physical activity. An audio record of these conversations will be kept. After eight weeks, a data collection similar to the initial one will be carried out again to identify if there are changes in your overall health. After these measurements, you will be invited to participate in music-based physical activity sessions designed specifically for breast cancer survivors. Your family members can also participate in directed  
  
physical activity classes, workshops and the meeting with the research group.  
Risks of the study: The taking of data to assess your health status does not pose risks to your health. During physical activity sessions there are risks of falls and injuries. To minimize these risks, physical activity classes have been adapted to their needs and limitations given by their underlying pathology. There will be the permanent accompaniment of personnel trained in life support during the physical activity classes, who in case you require urgent medical attention, will immediately call the emergency service of the Health Institution, will provide you with the necessary life support measures while you are referred to the attention by the emergency doctor. To be included in this study you must have affiliation to the health system and carry your membership card during all physical activity sessions.  
Benefits of the study: This study seeks to contribute to the quality of life of women survivors of breast cancer, motivating them to practice physical activity. Through your participation in the study, we want to make you aware of the multiple benefits that result from the habitual practice of physical activity. Just as we hope to understand and make visible your perceptions and your family´s in the face of the establishment of a program of direct physical activity, linked to the care of your health. The rumba sessions have been designed and will be offered by experts who have knowledge of the limitations that breast cancer patients present as a result of chemotherapy, radiotherapy or surgery treatment. Refreshments will be delivered in each of the activities and a gift will also be given as a thank you for your participation.

On behalf of the Universidad de los Andes, we extend a cordial invitation to participate in the study: "Mybody, my rhythm, my voice: Promotion of physical activity in breast cancer survivors in Colombia". If you decide to participate, your participation in the study will consist of attending rumba sessions (musicalized physical activity) and allowing the collection of data that will be detailed in this document.  
This is a study coordinated by Dr. Olga Lucía Sarmiento and her group of researchers; It has the support of the Faculty of Medicine of the Universidad de los Andes, in partnership with researchers from the Manuela Beltrán University, Stanford University, the League Against Cancer, the Ministry of Health, the District Institute of Recreation and Sports of Bogotá and the SIMMON Foundation. This document explains the different aspects of the research study: its purpose, the procedures to be performed, the risks of the procedures, and the potential benefits. Once you know what the study is about, you will be asked if you wish to participate, and if so, you will be asked to sign this written authorization.  
Purpose of the study: The purpose of this study is to see what the motivations and barriers are to attending physical activity sessions and what changes in physical and mental health occur as a result of the practice of physical activity. It also identifies barriers to ensuring the permanence of a program to promote physical activity in breast cancer survivors.  
Study Procedures: If you choose to participate, an appointment will be scheduled with you to assess your current health status by taking body composition and physical activity data. These measurements, which will be described below, will be carried out in the same institution where the physical activity sessions will be carried out.  
Body composition is assessed by a bio-impedanceometry test. This test is performed on special scales that have metal plates that conduct a type of weak electric current that passes through the entire body. Thanks to this current, these scales can calculate the amount of muscle, fat, and water in the body.  
To measure physical activity, you will be asked to use a portable motion meter (accelerometer); which is a device that gives objectively the amount of movement you perform during the day. The use of this meter does not alter your daily activities or generate discomfort or pain. The monitoring with this device will last twenty-four (24) hours during seven (7) consecutive days. To measure your functional capacity, we will perform a test called a 6-minute walk, which consists of measuring the maximum distance you can walk for 6 minutes without stopping. This measurement will be performed twice (during the first measurement, and 8 weeks later). This test will be carried out in a flat space, delimited by cones and without any obstacles. In addition to this, we will use a device called Polar (similar to a watch), which will be placed on your wrist, to measure your heart rate during the test.  
In this first measurement, you will also be asked to answer an initial survey on sociodemographic data, quality of life, anxiety, perception of fatigue and other health indicators. Likewise, you will be invited to a meeting with the other participants to discuss the main motivations for the practice of physical activity.  
After this, you will be invited to participate for 8 weeks in physical activity classes offered three times a week and led by trained staff. Some sessions will be accompanied by workshops of manual arts and healthy habits to be carried out in the same space of the physical activity sessions. Additionally, psychosocial support will be provided to strengthen behavioral change, through a pedagogical primer. Once the intervention is finished, measurements similar to the initial one will be made again to determine if you had any change in your health condition as an effect of the rumba classes. Finally, a meeting will be held to learn about your experience in physical activity classes; you will have an audio record of those meetings. Your family members can also participate in the directed physical activity classes, workshops, and the meeting with the research group.  
Study Risks: During physical activity sessions there are risks of falls and injuries. To minimize these risks, physical activity classes have been adapted to their needs and limitations given by their underlying pathology. There will be the permanent accompaniment of personnel trained in life support during the physical activity classes, who in case you require urgent medical attention, will immediately call the emergency service of the Health Institution, will provide you with the necessary life support measures while you are referred to the attention by the emergency doctor. To be included in this study you must have affiliation to the health system and carry your membership card during all physical activity sessions.  
Benefits of the study: This study seeks to contribute to the quality of life of women survivors of breast cancer, motivating them to practice physical activity through rumba sessions of an approximate duration of one hour each. The sessions have been designed and will be offered by experts who have knowledge of the limitations that breast cancer patients present as a result of chemotherapy, radiotherapy or surgery treatment.  
Through your participation in this study, we want to make you aware of the multiple benefits that result from the habitual practice of physical activity. Just as we hope to understand and make visible your perceptions and your family's in the face of the establishment of a program of direct physical activity linked to the care of your health. Refreshments will be delivered in each of the classes or workshops and other gifts will also be given as a thank you for your participation.

| Date: ___________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | Place: _______________________________________ Yes   | No   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------|------|
| I authorize audio recording and use for research purposes I authorize audio transcription and use for knowledge dissemination I authorize the taking of photos and their use for research purposes I authorize the taking of photos and their use for dissemination of knowledge Signatures: ______________________________________________________________________________ Name Signature or Fingerprint* Date CC ______________________________________________________________________________ Residence address City Phone  ______________________________________________________________________________ Witness 1 CC Date ______________________________________________________________________________ Witness2 CC Date ______________________________________________________________________________ Who applies the informed consent CC Date |                                                      |      |  
Project title: My body, my rhythm, my voice. **Promotion of physical activity in breast**  
  
cancer survivors in Colombia.  
Consent: By means of this consent I _____________________________________________ declare that the objective  
  
of this project has been clarified to me. I also declare that I have been offered the opportunity to resolve all my doubts regarding the study. I declare that I do not have any heart disease diagnosed so far. In addition, I place on record that I read and understood the contents of this document.  
*The fingerprint of the participants is requested in case they do not know how to read and / or write

Consent: By means of this consent I _____________________________________________ declare that the  
  
objective of this project has been clarified to me. I also declare that I have been offered the opportunity to resolve all my doubts regarding the study. I declare that I do not have any heart disease diagnosed so far. In addition, I place on record that I read and understood the contents of this document.  
| Date: ___________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | Place: _______________________________________ Yes   | No   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------|------|
| I authorize audio recording and use for research purposes I authorize audio transcription and use for knowledge dissemination I authorize the taking of photos and their use for research purposes I authorize the taking of photos and their use for dissemination of knowledge Signatures: ______________________________________________________________________________ Name Signature or Fingerprint* Date CC ______________________________________________________________________________ Residence address City Phone  ______________________________________________________________________________ Witness 1 CC Date ______________________________________________________________________________ Witness2 CC Date ______________________________________________________________________________ Who applies the informed consent CC Date |                                                      |      |  
*The fingerprint of the participants is requested in case they do not know how to read and / or write