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TITLEHERE

TOPICHERE

REASONHERE

We ask that you read this document and ask any questions you may have before agreeing to be in the study.

AFFILIATIONHERE

Background Information:

PURPOSEHERE

Procedure:

PROCEDUREHERE

Risks and Benefits of Being in the Study:

The study has the following risks: RISKSHERE

BENEFITSHERE

COMPHERE

Confidentiality:

CONFHERE

Voluntary Nature of the Study

COOPHERE

New Information

NEWINFOHERE

Contacts and Questions

RNAMEHERE

You may ask any questions you have now.

RADDRESSHERE

ROTHERHERE

You will be given a copy of this form to keep for your records.

Statement of Consent:

I have read the above information. I have asked questions and have received answers. I consent to participate in the study.

SIGHERE PROXYHERE PARENTHERE Signature of Investigator or Person Obtaining Consent ________________________ Date ___________


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