Biomedical and Scientific Research Ethics Committee Study Number: BSREC-999999

Title of Project: Widget Usability

Names of Researchers: John Doe and Dr Charlie Clever

Please sign all boxes

• I confirm that I have read and understand the information sheet dated 1 March 2015 for the above study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily.
  
• I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason, without my education or legal rights being affected.
• I agree to take part in the above study.

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