SIGNATURE OF INVESTIGATOR DATE (If different from person obtaining consent) EMERGENCY PHONE NUMBER RESEARCH SITE Template Legally Authorized Representative (LAR) signature section: <<If applicable (if it is a study involving cognitively impaired participants): I certify that under state law I am the legally authorized representative of the participant named above and that I am authorized to sign this consent to his/her participation in the research study described in this form. I am also authorized to allow the use and sharing of the participant’s study-related records as describe in this consent. By what means do you have authority to give permission for the subject? (check one) Appointed Guardian Power of Attorney Health Care Agent/Proxy (Advance Directive) Relationship to subject (e.g. spouse, parent, etc. describe) ___________________ – (describe)___________________________________________ _______________________________________ _______________ ___________ Signature of Legally Authorized Representative Printed Name Date Template Witness Statement section: <<If no LAR and the study is not enrolling minors: WITNESS STATEMENT As an impartial third party, I witnessed the entire consent discussion and the participant’s signature on this form. If the witness is required because the participant is not able to read this consent form, and the study center and the protocol allow enrollment of people who cannot read, please also check the box below:
SIGNATURE OF INVESTIGATOR DATE (If different from person obtaining consent) EMERGENCY PHONE NUMBER RESEARCH SITE Template Legally Authorized Representative (LAR) signature section: <<If applicable (if it is a study involving cognitively impaired participants): I certify that under state law I am the legally authorized representative of the participant named above and that I am authorized to sign this consent to his/her participation in the research study described in this form. I am also authorized to allow the use and sharing of the participant’s study-related records as describe in this consent. By what means do you have authority to give permission for the subject? (check one) Appointed Guardian Power of Attorney Health Care Agent/Proxy (Advance Directive) Relationship to subject (e.g. spouse, parent, etc. – describe) ___________________ (describe)___________________________________________ _______________________________________ _______________ ___________ Signature of Legally Authorized Representative Printed Name Date Template Witness Statement section: <<If no LAR and the study is not enrolling minors: WITNESS STATEMENT As an impartial third party, I witnessed the entire consent discussion and the participant’s signature on this form. If the witness is required because the participant is not able to read this consent form, and the study center and the protocol allow enrollment of people who cannot read, please also check the box below: