◆様式4-2：研� �参加に関する� ��意撤回書.pdf

Withdrawal of Consent Form

I withdraw my consent to participate in the research project titled " " as a research subject.
□ I withdraw all consent.
□ I withdraw part of my consent.
□ I withdraw consent for the storage and use of samples and information after the research is completed.
□ I withdraw consent for .

Please notify me of the response to this withdrawal request
□ by document
sent to
□ by phone
with phone number
□ by email
with address
as soon as possible.

Date: Year Month Day
Name of person withdrawing consent (signature/seal)

Seal

This withdrawal form can also be submitted by fax or email.
Fax number: ○○○—○○○○—○○○○（○○○○）
Email address: ○○○○＠○○○○○○○（○○○○）
If the research director is not available to receive contact, please provide the direct phone number, fax number, and email address of the research staff member who can receive contact, followed by the staff member's name in parentheses.