 |
 |
|
TITLEHERETOPICHEREREASONHERE We ask that you read this document and ask any questions you may have before agreeing to be in the study. AFFILIATIONHERE
Background Information:PURPOSEHERE
Procedure:PROCEDUREHERE
Risks and Benefits of Being in the Study:The study has the following risks: RISKSHEREBENEFITSHERE COMPHERE
Confidentiality:CONFHERE
Voluntary Nature of the StudyCOOPHERE
New InformationNEWINFOHERE
Contacts and QuestionsRNAMEHEREYou may ask any questions you have now. RADDRESSHERE ROTHERHERE You will be given a copy of this form to keep for your records.
Statement of Consent:I have read the above information. I have asked questions and have received answers. I consent to participate in the study.SIGHERE PROXYHERE PARENTHERE Signature of Investigator or Person Obtaining Consent ________________________ Date ___________
|