ANEXO I: Declaración de consentimiento informado.

DECLARACIÓN DE CONSENTIMIENTO INFORMADO

D. /Dña.…………………………, de…. años de edad y con DNI nº ……….., manifiesta que ha sido informado/a sobre los beneficios que podría suponer la participación en el screening auditivo/visual para cubrir los objetivos del Proyecto de Tesis Doctoral titulado “IMPACTO DE LA PÉRDIDA AUDITIVA Y VISUAL EN LA CAPACIDAD COGNITIVA DE LA POBLACIÓN GALLEGA MAYOR DE 60 AÑOS ” con el fin de mejorar la calidad de vida de la población Gallega.

He sido informado/a de los beneficios que la participación en el proyecto puede tener sobre mi bienestar y salud.

He sido también informado/a de que mis datos personales serán protegidos e incluidos en un fichero que deberá estar sometido a y con las garantías de la ley 15/1999 de 13 de diciembre.

Tomando ello en consideración, OTORGO mi CONSENTIMIENTO a que tenga lugar la valoración auditiva y visual y que sea utilizada para cubrir los objetivos especificados en el proyecto.


Fdo. D/Dña.

ANEXO II: Hearing-Dependent Daily Activities Scale (HDDA; Lopez-Torres et. al.)

ANEXO III: Functional Vision Screening Questionnaire (FVSQ; Horowitz A. et al.)

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