INFORMED CONSENT FORM

I have understood the oral explanation of this survey, and/or I have read the fact sheet that explains the reasons for this survey (for literate subjects). I understand that:

- I am invited to participate in the survey and I am informed of the implications of my participation;

- I may stop my participation at any time without giving any reason and that this will not interfere with my job.

- My interlocutor has answered all my questions regarding this survey in a clear and satisfactory manner.

- I hereby give my consent to participate in this survey.

Identification number in the study: /__/__/__/__/__/__/__/__/__/

Participant:

Date:

Signature:

Person collecting consent:

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Date:

Signature: