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Appendix 4: Informed Consent

FREE and INFORMED CONSENT FORM

I have read and understood the Information Sheet. The procedures have been explained to me and all of my questions have been answered to my satisfaction. I have been informed that I can withdraw from the study at any time without penalty and that, if I choose to do so, any data collected as a result of my participation will be destroyed. The potential discomforts that I might experience because I have participated in the study have been explained to me. I also understand the potential benefits of being a part of this study.

I know that I may ask now, or at any time in the future, any questions I have about the study. I have been assured that the audio and written records related to this study will be kept confidential to the limits of the law. I have also been assured that no information will be released or printed or made public that would disclose my personal identity unless I give permission for that to happen.

I hereby consent to participate

Printed Name of Participant: ____________________________

Date: ____________________________

Signature of Participant: ____________________________

I hereby consent to having my interview audio recorded

Signature of Participant: ____________________________

Date: ____________________________

Printed Name of Monitor: ____________________________

Date: ____________________________

Signature of Monitor: ____________________________

 

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