Withdrawal of Participation

50%

I wish to WITHDRAW my participation in the ‘Join Us’ register. I request that the ‘Join Us’ register handles the information they have collected about me in the following way:

Choose one option (Where both boxes are ticked, or neither box is ticked, we will destroy all information that has been collected about you):

Destroy all information collected about me (both personal identifiers and de-identified health data) so it can no longer be used for research and do not contact me about future studies.Retain the de-identified health data collected about me to date but delete my contact details from the database, do not collect any further information about me and do not contact me about future studies.

I understand that:

No further information about me will be collected for the ‘Join Us’ register from the withdrawal date;
Information about me that has already been analysed and/or included in a publication may not be able to destroyed;
Choosing to withdraw from the ‘Join Us’ register will not affect my access to health services or government benefits;
Choosing to withdraw from the study will not affect my relationship with the George Institute Australia or the University of New South Wales.

100%

First Name

Last Name

Date of Birth

Contact Information