Consimtamant informat

Subsemnatul:_______________________________________________________ Date CI:___________________________________________________________ Domiciliu:_________________________________________________________ Declar pe propria raspundere urmatoarele:- Sufar/Nu sufar de boli psihice. (tratament, spitalizare, daca este cazul)

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- Sufar/Nu sufar de alte boli. (tratament, spitalizare, daca este cazul)________________________________________________________________________________________________________________________________________________

- Am fost/Nu am fost evaluat psihologic in ultimul an.- Detalii privind evaluarile psihologice anterioare. (daca este cazul)

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- Am consumat/Nu am consumat in ultimele 24h bauturi alcoolice.- Am consumat/Nu am consumat in ultimul an substante interzise sau etnobotanice.- Am/Nu am alte motive pentru a nu fi apt sa sustin evaluarea psihologica.

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Sunt de acord ca rezultatele evaluarii psihologice sa fie utilizate in procesul de resurse umane de catre: _________________________________________________

Data: Semnatura: