Signature of Subject: __________________________________ Date: ________________ Name (Print legal name): ___________________________________________________________ Video, Audio, and Photo: I understand that this study will utilize video and/or still photography to analyze study results and I consent for the use of these materials. N/A I accept I do not accept Signature: _____________________________ Principal Investigator (or Designee): I have this subject information about this study. I believe this to be accurate and complete. The subject has indicated that he or she understands the nature of the risks and benefits of participating in this study. Name: ____________________________________ Title: ___________________________ Signature: _________________________________ Date: ___________________________ Witness (optional): I observed the above subject sign this consent document. Name: ________________________________ Signature: _____________________________ Date: _________________________
Signature of Subject: __________________________________ Date: ________________ Name (Print legal name): ___________________________________________________________ Video, Audio, and Photo: I understand that this study will utilize video and/or still photography to analyze study results and I consent for the use of these materials. N/A I accept I do not accept Signature: _____________________________ Principal Investigator (or Designee): I have this subject information about this study. I believe this to be accurate and complete. The subject has indicated that he or she understands the nature of the risks and benefits of participating in this study. Name: ____________________________________ Title: ___________________________ Signature: _________________________________ Date: ___________________________ Witness (optional): I observed the above subject sign this consent document. Name: ________________________________ Signature: _____________________________ Date: _________________________
nasaIRB-ResearchConsentLayTemplate%20Rev%20%205%201%202014.docx