Compensation for trial participants
1. 	What payments or compensation, if any, are the trial participants to receive? 
☐   none, please explain why not  Click or tap here to enter text.
☐   travel expenses 
☐   monetary payment, namely (in Euro’s)  Click or tap here to enter text.
☐   other form of payment or compensation, namely  Click or tap here to enter text.
	
2. 	If monetary payment is offered, please indicate how this amount came about (including justification): Click or tap here to enter text.
	
3	If non-monetary payment is offered, please specify the type and value of the benefit with justification: Click or tap here to enter text.	
4	Can you indicate why you are of the opinion that the payment or compensation does not disproportionately influence the voluntary participation in the clinical trial: Click or tap here to enter text.	
5	Are there any conditions attached to the payment or compensation? (for example, where the full trial or stages of the trial must be completed)
☐  not applicable       
☐  no        
☐  yes, please describe Click or tap here to enter text.	

Compensation for investigator1/funding clinical trial/ other arrangements
1. 	Will compensation (including non-monetary payment) be offered to the investigator/clinical trial site? (select only one box)
☐   No, please explain Click or tap here to enter text.
☐   Yes, please specify Click or tap here to enter text.  
	
2. 	How is the clinical trial funded?
☐   Category 1 funding (direct funding by the Ministry of Education, Culture and Science of by a University medical centre)
☐   Category 2 funding (direct funding by NWO, ZonMW or KNAW), namely Click or tap here to enter text.  
☐   Category 3 funding (other than category 1 or 2, such as charity institutions, European Commission, Industry, etc), namely Click or tap here to enter text.  
	
3. 	Is the clinical trial (in part) funded by industry/companies?
☐   No
☐   Yes, by the industry/company who is the sponsor of the clinical trial
☐   Yes, (also) by industry/companies other than sponsor, namely Click or tap here to enter text.	
4.	Are there any agreements between the sponsor and the clinical trial site?
☐   No
☐   Yes, clinical trial agreement (go to question 5) 
☐   Yes, other agreement, please specify Click or tap here to enter text.	
5.	5a. Do the conditions in the clinical trial agreement on “publication and authorship” comply with the standard clauses of the Dutch model clinical trial agreement2 (CCMO guideline on assessment clinical trial agreement) and the principles of the Declaration of Helsinki?
☐   Yes
☐   No, other conditions, please specify (including justification)   Click or tap here to enter text.

5b. Do the conditions in the clinical trial agreement on “term and termination” comply with the standard clauses of the Dutch model clinical trial agreement2 (CCMO guideline on assessment clinical trial agreement )?
☐   Yes
☐   No, other conditions, please specify (including justification)   Click or tap here to enter text.