PDARGREK Patient Enrolment and Consent Form for Patient Access Program Patient information Full Name: Date of Birth: DO jy, Address Line 1 city State: Pincode: Phone number: Email 10: [IF PATIENT IS A MINOR (less than 18 years) PLEASE ADD FOLLOWING INFORMATION: ] ‘ent/carer information Full Name: Date of Birth: ‘Address Line 1 cay: State Pincode: Phone number: Email 1D ‘Treating physician information: Name of Physician: Hospital: city Prescribed Product: pate Dear Patient/carer, ‘Thank you for your intrest n joining the Rainbow Program. This Is an Intlatve by Merck Oncelegy and managed by- Merck. The program Is esigne to afar support to patents on the access of arcgs ahd patent safety information. The Raltbow Program Is provided to you by Merck Specialties Private Limes, CIN, Godre) One, Sth floor, Drofshanagar, Eastam Express Highway, Vehrl East, Mumba-€00079, Phone no $$9t-22-62109000 ("Merdk). Tol free number’ 18001200050. 1. Terms of use 4, What is Rainbow Program and its term? Rainbow program is designed to offer supper to patients on the access of drust- Merck reserves the ight to ater and/or terminate the 2. abliey fon ch te coreoual parte my ey oh ese soigeon) an brite t te typal ond freseeblecomge oy, th 11, Privacy Notice {mn the course of Rainbow program, the following data are collecte der, email adress, phone number, contact nformaton, name eating doctor oF aster data (or example: name, date of bith, Data collected when providing the services progrom about your treatment, condition and services provided to you (for example: current ies statun, appoitments, information and material submttee #0 you, noes about conversations, Feedback povises by you) Information transmitea by the injection device (for example: date, tme, dose injected) [NA]PARGREK 12) Use of data for providing servis to patente Merck, wil have access to your deta and will use t to implement the Rainbow progrom. Supervisors and local administrators of Merce may ecesionlly acess yor data inorder 9 review ang advise onthe services rowed to patients an fo review te evel of service 2) Use of data for T Services ‘All data vill be stored In hard disk, patent relationship management portal and hard copy (any). Merck can access data for the maintenance, operation a” administration of your data, he software or database But only tothe exten required, that access may also {ke place fom ather loatlons; Merck wil take all teps reasonably necessary to ensure thatthe data yeu provide is adeauataly protected according tothe requirements of the apacabie data protection ls, ‘support a decision about o single patient. “ 4) paverse events Reorter may share personal information with Merk n case of adverse even tothe treatment, or» product relates issue, Merck may Use the information fo the pursore of cr safety surveil and may snare wth nea authortesn India or ouside Inds During the term of the Rainbow program, Merck may appoint external service provider Of course the data collected andthe purposes for which your cata wil be used will not change 4. Voluntary participation, right to withdraw and further rights: ‘You ae free to withraw your consent to participate n Ralndow program at any time, for example by informing -Merck of course, hs wil not afect the treatment you receive ram your dolores or our previous use a your data; wil Just alec your ature paripation ‘Your data will be stored while you participate inthe Rainbow program and afer that fora period of 1 year after completion of therapy ot Aropout fom therapy. Marck and Merc companies may Keep data for staistal. You ave aright to reguest access to Your personal dat, Fecelve a copy of Your personal data ina commen electronic data format, the copy of clauses used for access of Your data and te Pht It you have any questions you can contact the Merck's data protection officer at corpsectmerckoroup.com or your lo author enrol mye in the Rainbow program. Name of patient [OR parent/carer] ‘Signature! vate: Completed by the patient (OR parent/carer]