SAMPLE CONSENT FORM

Here are items to be considered for inclusion in a consent form:

· You are being asked to participate voluntarily in a research project entitled __________ that is being organized by _________________________.

· The aims of this study are ___________________________.

· If you agree to participate, you will be asked to ________________________..

· Your participation in this project is entirely voluntary and there will be no negative consequences if you refuse to participate in it, withdraw from it, or refuse to answer certain questions.

· Your anonymity will be maintained by _____________________ and your identity will not be revealed to others (except____________.)

· Confidentiality regarding the information that you provide will be assured by __________________..and your individual answers will not be shared or presented in any way that would identify you as the source (except_________)

· The benefits of participating in this study include_________.

· The costs/inconveniences/risks of participating include______..

· At the conclusion of this study, the information collected will be____________..

· The results of this study will be used__________________.and presented at_______________

· If you have any questions or concerns about the project itself or the methods used, you should contact (researcher's name and contact information including phone number).

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Having understood the above information and after being given an opportunity to have my questions answered, I agree to participate in this study.

Signature of Participant Date

Co-Signature (if required) Date