8/19/2019 II Sample Informed Consent Form

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INFORMED CONSENT FORM

Research Title: ..................................................

Researcher’s Name: .........................................

I, ………………………………………, IC No : …………………......• have read the information in the Patient Information Sheet including

information regarding the ris in this stud!• have been given time to think about it and all of my questions have been

ansered to my satisfa!tion.• understand that I may freely !hoose to ithdra from this study at

anytime ithout reason and ithout re"er!ussion• understand that my anonymity ill be ensured in the rite#u".

I voluntarily agree to be "art of this resear!h study, to follo the study"ro!edures, and to "rovide ne!essary information to the do!tor, nurses, or othersta$ members, as requested.

………………………………. …………………..%Signature& %'ate&

……………………………….(itness %if any&

……………………………….%Signature&

……………………………….%IC Number&

…………………………..…%'ate&

……………………………….)esear!her

……………………………….%Signature&

……………………………….%IC Number&

……………………………….%'ate&