MEDICAL DEANS AUSTRALIA AND NEW ZEALAND

MEDICAL SCHOOLS OUTCOMES DATABASE AND
LONGITUDINAL TRACKING PROJECT

REVOCATION OF CONSENT

We understand that you have decided to withdraw your consent to continue to participate in the Medical Schools Outcomes Database (MSOD) and Longitudinal Tracking Project. We acknowledge that your participation in the project is entirely voluntary and that you can withdraw at any time.
We have taken great care to ensure that the data collected remains confidential and that your privacy is protected, by keeping the MSOD database separately from your personal information, in the following way:

  1. the consent form (with your name) is stored at your medical school
  2. the data you provide (which contains your Student Identification Number as the only means of identification) is stored centrally and separately from your medical school

That's why we need you to acknowledge your withdrawal by completing both parts of this form to make sure that all the necessary people are informed.

Please complete Part 1 AND Part 2

__________________________________________________________________________

PART 1: for Medical School records
(to be forwarded by MSOD to the Faculty administrative staff and attached to consent form staff)

 

I wish to withdraw my consent to participate in the Medical Schools Outcomes Database (MSOD) and Longitudinal Tracking Project and understand that such withdrawal will not affect my progress within my Medical program.

 

..................................................................                  ………………………………
Name                                                                       University Student ID

 

 

_________________________________________________________________________________

PART 2: for MSOD Management records  

We understand that you have decided to withdraw your consent to continue to participate in the Medical Schools Outcomes Database (MSOD) and Longitudinal Tracking Project.

As it is customary to continue to use the data collected in a longitudinal study up to the point of withdrawal for future analysis and data linkage, we need clear instructions from you to indicate what action you require us to take.  

For this reason we need you to specify which of the actions listed below you would like us to take. PLEASE COMPLETE ONE OPTION ONLY.

 

……………………………………………….
University Student ID

I wish to withdraw my consent to continue to participate in the Medical Schools
Outcomes Database (MSOD) and Longitudinal Tracking Project and that I not be
asked to complete any further questionnaires or receive any further communication from the study team.

Furthermore, I request that:


the data collected up until the time of withdrawal can be used by the research team and linked to external databases, under strict privacy protocols.


the data collected up until the time of withdrawal can be used by the research team but not linked to external databases.


all data collected up until the time of my withdrawal be removed

OPTIONAL
My reasons for withdrawing from this MSOD are as follows:

………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
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Further information on the project, and reports and publications prepared using the database are available from MSOD Project website: http://www.medicaldeans.org.au/msod.html

To be forwarded to:

MSOD
 Medical Deans Australia and New Zealand
Medical Foundation Building (K25)
The University of Sydney, NSW 2006

Email: bkaur@medicaldeans.org.au