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別添 研究参加の同意書 ver2.2 2023/08/30
研究参加の同意書
京都大学大学院医学研究科長 殿
説明を受け、以下の項目を理解し、簡易型オンライン間欠的断食プログラムの減量効果を検証するランダ
ム化パイロット研究に参加することに同意します。
1. 研究実施について
2. 研究機関
3. 研究の目的および意義
4. 研究方法およびスケジュール
5. 研究対象者の選定基準と除外基準
6. 研究参加者に生じる負担と、予想されるリスクおよび利益
7. いつでも同意の撤回ができます
8. 研究に同意しない、または同意撤回において不利益はないこと
9. 研究に関する情報公開について
10. 研究計画書等の閲覧について
11. 個人情報の取扱いについて
12. 試料・情報の保管および廃棄の方法
13. 研究資金および利益相反について
14. 研究より得られた結果の取り扱い
15. 相談の窓口
16. 経済的負担/謝礼について
17. 試料・情報の将来の研究における使用および他機関への提供
説明日 (西暦) 年 月 日
同意日 (西暦) 年 月 日
本人氏名(自筆)
説明者 氏名(自筆) (所属)
※同意書のコピーを一部必ずもらってください

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研究参加の同意書_参加者さま.pdf

  • 1. 別添 研究参加の同意書 ver2.2 2023/08/30 研究参加の同意書 京都大学大学院医学研究科長 殿 説明を受け、以下の項目を理解し、簡易型オンライン間欠的断食プログラムの減量効果を検証するランダ ム化パイロット研究に参加することに同意します。 1. 研究実施について 2. 研究機関 3. 研究の目的および意義 4. 研究方法およびスケジュール 5. 研究対象者の選定基準と除外基準 6. 研究参加者に生じる負担と、予想されるリスクおよび利益 7. いつでも同意の撤回ができます 8. 研究に同意しない、または同意撤回において不利益はないこと 9. 研究に関する情報公開について 10. 研究計画書等の閲覧について 11. 個人情報の取扱いについて 12. 試料・情報の保管および廃棄の方法 13. 研究資金および利益相反について 14. 研究より得られた結果の取り扱い 15. 相談の窓口 16. 経済的負担/謝礼について 17. 試料・情報の将来の研究における使用および他機関への提供 説明日 (西暦) 年 月 日 同意日 (西暦) 年 月 日 本人氏名(自筆) 説明者 氏名(自筆) (所属) ※同意書のコピーを一部必ずもらってください