Discussed this study with an investigator Reviewed the information in this form Had the opportunity to ask any questions you may have. Your signature below means that you have received this information, have asked the questions you currently have about the research, and have received answers to those questions. You will receive a copy of the signed and dated form to keep for future reference. Participant: By signing this consent form, you indicate that you are voluntarily choosing to take part in this research. __________________________ __________ ________ ________________________ Signature of Participant Date Time Printed Name Participant’s Legally Authorized Representative: By signing below, you indicate that you give permission for the participant to take part in this research. __________________________ __________ ________ ________________________ Signature of Participant’s Legally Date Time Printed Name Authorized Representative The signature of the participant’s legally authorized representative is required for people unable to give consent for themselves. Description of the Legally Authorized Representative’s Authority to Act for Participant Person Explaining the Research: Your signature below means that you have explained the research to the participant or participant representative and have answered any questions about the research. __________________________ __________ ________ ________________________ Signature of person who Date Time Printed Name explained this research Only approved investigators for this research may explain the research and obtain informed consent. A witness or witness/translator is required when the participant cannot read the consent document, and it was read or translated. NOTE: The following applies to optional parts of the research only, e.g., storage of leftover tissue for future research, optional substudies, etc.
Discussed this study with an investigator Reviewed the information in this form Had the opportunity to ask any questions you may have. Your signature below means that you have received this information, have asked the questions you currently have about the research, and have received answers to those questions. You will receive a copy of the signed and dated form to keep for future reference. Participant: By signing this consent form, you indicate that you are voluntarily choosing to take part in this research. __________________________ __________ ________ ________________________ Signature of Participant Date Time Printed Name Participant’s Legally Authorized Representative: By signing below, you indicate that you give permission for the participant to take part in this research. __________________________ __________ ________ ________________________ Signature of Participant’s Legally Date Time Printed Name Authorized Representative The signature of the participant’s legally authorized representative is required for people unable to give consent for themselves. Description of the Legally Authorized Representative’s Authority to Act for Participant Person Explaining the Research: Your signature below means that you have explained the research to the participant or participant representative and have answered any questions about the research. __________________________ __________ ________ ________________________ Signature of person who Date Time Printed Name explained this research Only approved investigators for this research may explain the research and obtain informed consent. A witness or witness/translator is required when the participant cannot read the consent document, and it was read or translated. NOTE: The following applies to optional parts of the research only, e.g., storage of leftover tissue for future research, optional substudies, etc.
NCCIH_Informed_Consent_Template_07-17-2015.docx