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It explains how a patient organization acts as data controller, the types of personal data collected (contact and patient data), storage in secured databases, and use of pseudonymized worksheets for analysis, scientific and statistical research. It sets out consent requirements, withdrawal rights, data subject rights under GDPR, retention approach, and limits on disclosure and cross-region sharing.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/informed-consent-form-participation-in-patient-journey-through-the-eu-survey-platform/176768/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/informed-consent-form-participation-in-patient-journey-through-the-eu-survey-platform/176768.png","ImageObject",442,249,{"name":88,"@type":89},"Jacob","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-22","2026-09-02",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who can sign this informed consent form?","Question",{"text":109,"@type":110},"A patient or an authorized representative of a patient can sign by checking the appropriate option.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What personal data may be collected and how is it used?",{"text":114,"@type":110},"Contact details and patient data may be collected. Contact data is used for registration and contacting the relevant person, while patient data is entered into worksheets and pseudonymized for analysis, scientific and statistical research.",{"name":116,"@type":107,"acceptedAnswer":117},"Can consent be withdrawn and what happens after withdrawal?",{"text":118,"@type":110},"Yes. Consent can be withdrawn at any time by notifying the organization by e-mail or mail, after which processing of the personal data stops.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},176768,1790120748,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},962084931830,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","TEMPLATE FORM – TO BE CUSTOMIZED BY NATIONAL PATIENT ORGANIZATION\n[This template can be used to collect data from patients that live in Belgium, The Netherlands, Spain, Portugal and Germany.  Should you want to use this consent form in another country, you will need to check if it complies with the data protection rules that apply in that country].\nInformed consent form \u0005\u000bParticipation in “patient journey” through the EU Survey Platform for [to be completed]\u0005\n\u0003☐\u0004 I am a patient\n\u0003☐\u0004 I am the authorized representative of a patient\nName\nE-mail address\nPhone number\n\u0003☐\u0004 Yes, I would like to participate in a patient journey through the EU Survey Platform.\nIf you agree to participate in a patient journey through the EU Survey Platform, [name patient organization] will process certain personal data, as described below, and need to obtain consent as further described below. [Name patient organization] will act as the controller for the processing of those personal data.\nYour data, your rights\nAll personal data which is collected in the context of the patient journey through the EU Survey Platform is processed by and on behalf of [name patient organization] as data controller, with its registered office at [address].\n[Name patient organization] aims to conduct patient journey surveys in order to enhance the knowledge and available data about the patients’ needs in relation to the provision of healthcare and social services [include the name of the disease(s)].\nThe following personal data may be collected and processed on the basis of this informed consent form:\nContact details (name, e-mail address, phone number) of the person(s) signing this informed consent form (\"Contact Data\");\nPersonal data of the patient, including name, contact details, age, date of birth, gender, nationality, data concerning health (including but not limited to disease, symptoms, diagnosis, physical condition, treatments, disease history, quality of life, [other]) (\"Patient Data\"). \u0005\nThe Contact Data and Patient Data will be stored in a secured database which is only accessible for employees and representatives of [name patient organization] on a strict need-to-know basis.\nThe Contact Data provided via this informed consent form will be used for the following purposes: registering the informed consent and contacting the relevant person in the context of the patient journey through the EU Survey Platform.\nThe Patient Data collected in the context of the patient journey through the EU Survey Platform, or as otherwise provided to [name patient organization] by the patient or by its authorized representative, will be entered into standard forms, which do not contain identification data of the patient or its authorized representative, such as name, e-mail address and phone number (\"worksheets\").\n[Name patient organization] will use the pseudonymized data included in the worksheets for the following purposes: analysis, scientific and statistical research in connection with the provision of health and social services. The aggregated results thereof may be shared with third parties through conferences, publications, websites, interviews and [other].\u0005\nThe personal data, including both Contact Data and Patient Data, which is collected in the context of the patient journey through the EU Survey Platform is processed on the basis of consent, as expressed in this consent form. The patient or its authorized representative are free to decide whether or not to sign this consent form; if not, then [name patient organization] will not process any personal data that may have already have been provided to [name patient organization] and will immediately delete those personal data.\nAny person signing this consent form, is at any time thereafter free to withdraw its consent for the processing of the personal data, without giving any reason, by notifying it by e-mail to [e-mail address] or by mail to [insert address]. \u0005Upon the withdrawal of your consent, the processing of your person","cbCaitB8sus3qsSI","https://ap.wps.com/l/cbCaitB8sus3qsSI","docx",45649,"English","# Participation in patient journey through the EU Survey Platform\n## Consent options and participant selection\n## Purpose and types of personal data collected\n## Data storage, pseudonymization, and research use\n## Consent, withdrawal, and mandatory co-signing (if applicable)\n## Data access, rights under GDPR, complaints\n## Disclosure limits and data retention","[{\"question\":\"Who can sign this informed consent form?\",\"answer\":\"A patient or an authorized representative of a patient can sign by checking the appropriate option.\"},{\"question\":\"What personal data may be collected and how is it used?\",\"answer\":\"Contact details and patient data may be collected. Contact data is used for registration and contacting the relevant person, while patient data is entered into worksheets and pseudonymized for analysis, scientific and statistical research.\"},{\"question\":\"Can consent be withdrawn and what happens after withdrawal?\",\"answer\":\"Yes. Consent can be withdrawn at any time by notifying the organization by e-mail or mail, after which processing of the personal data stops.\"}]","Informed Consent Form - Participation in patient journey through the EU Survey Platform | DOCX",1788325498]