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Principal Investigator:


  1. Purpose:

  2. Procedures:

  3. Discomforts and Risks:

  4. Benefits:

  5. Duration or Time:

  6. Statement of Confidentiality:

  7. Right to Ask Questions: You have the right to ask questions and to have questions answered.

  8. Compensation: You will not receive monetary compensation for participating in this study.

  9. Voluntary Participation: You do not have to participate in this study. You can end your participation at any time by telling the person in charge. You do not have to answer any questions that you do not want to answer.

    You must be 18 years of age or older to consent to participate in this study. If you consent to participate in this study and to the terms above, please sign your name and indicate the date below. You will be given a copy of this form to keep for your records.

    __________________   ____________

    Participant Signature   Date

    I, the undersigned, verify that the above informed consent procedure has been followed.

    ___________________   ____________

    Investigator Signature   Date

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