| wd_type |
|
checkbox |
Withdrawal Type |
1, I wish to withdraw from the study. I no longer wish to be contacted about the research or be asked to provide additional samples or information. I agree that the study team can continue to access data from my electronic records. ; 2, I wish to withdraw from the study. I no longer wish to be contacted about the research or be asked to provide additional samples or information. My electronic records should no longer be accessed by the study team. |
| wd_sign_type |
|
radio |
Person Signing Withdrawal Form |
1, Participant ; 2, Signatory other than participant |
| wd_pt_signature_verified |
|
yesno |
Participant signature verified? |
1, Yes ; 0, No |
| wd_date |
|
text |
Withdrawal Date |
|
| wd_signatory_date_verified |
|
yesno |
Signatory verified? |
1, Yes ; 0, No |
| wd_signatory_date |
|
text |
Signatory Date |
|