Samples of Certificate

Informed Consent

Informed Consent

I, Age , resident of voluntarily and of my own free will, consent to participate in the research project titled “” being conducted by Dr. , who is the principal investigator, in the Department of , .

I have received a copy of the patient’s information pamphlet related to this project and have read it / it has been read to me. The principal investigator has clarified my doubts to my satisfaction.

I have been informed by the Principal investigator clearly, in a language that I can understand that the main purpose of the project is to study the .

  1. The study requires me to fill a questionnaire being provided to me with questions pertaining to the disorder I am having/ undergo a treatment the effects and side effects of which has been explained to me clearly. I have been informed that the result of the study will be of benefit to the medical care by filling the gaps in medical knowledge.
  2. In case I refuse to participate or withdraw consent at a later date, it will not jeopardize my care, there will be no prejudice against me and I will continue to receive the best available facilities at this institute.
  3. There is no extra cost required from my side for my participation.
  4. I have been informed that the confidentiality of the records will be maintained and in case of the publication of material, I will not be identified by name/images unless I give written consent or if it is required by law/enforcement agencies/privileged communication.
  5. The material for the present study will not be used in other studies or for the purposes other than defined in the present project or related to the present subject. Strict confidentiality will be maintained.
  6. The above has been explained to me in the language I understand. I have been informed that I can contact the project principal investigator Dr. at any time on mobile no. and in case of any other factor, the Director Principal or Professor-in-charge Academics, , .

Signature of the Participant/ of the Guardian

Name

Address



Signature of Principal Investigator.

Date:

Signature of the Witness

Name

Address

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