Survey_database

Thank you for your interest in participating in clinical research at ITM.
By completing this questionnaire, you will be registered in our database and we will keep you informed about new studies by e-mail. If you are interested in a specific study, we will ask you to complete a separate questionnaire.

Personal information

First name *

Last name *

Date of birth * +

Sex *

M

F

O

E-mail *

Telephone / mobile phone *

Postal code *

Town/City *

Country *

Comments

Please enter your comments here (eg: chronic conditions, ...)

Privacy statement online contact database for clinical trials

Your personal data requested in this form are intended to create a database of potential participants in future scientific research. This data will allow an initial assessment to determine your eligibility to participate in a study and to invite you to potentially appropriate future studies.

The Institute of Tropical Medicine (ITM) is responsible for processing your personal data. The legal basis for processing your personal data is your consent. This consent is revocable at any time. Your personal data will be processed in accordance with the General Data Protection Regulation (GDPR). This data will be kept strictly confidential and will not be shared outside the authorized persons of the ITM.

Subscription to this list is completely voluntary. You always have the right to see your data, correct it if necessary and have it deleted.

Your data will be kept for an indefinite period of time. When your personal data are no longer needed for the above-mentioned purpose, they will be destroyed. If you wish, you can always unsubscribe prematurely by sending an e-mail to infoctc@itg.be.

If you have any further questions about the processing of your data, please contact us on 03 247 07 43 or informatieveiligheid@itg.be.

*

I have read the Privacy Statement and consent to the processing of my personal data as described herein.

You are at the end of the survey.

Please click the 'Submit' button below to finish.