Research Consent Form
for Vulnerable Populations

Study Title

Principal Investigator

Purpose of the Study

Procedures

Potential Risks and Discomforts

Potential Benefits

Confidentiality

Voluntary Participation

Contacts for Questions

Consent Statement

I have read and understood the above information and have had the opportunity to ask questions. I agree to participate in this study. I understand my participation is voluntary and that I may withdraw at any time.

Participant's Name

Date

Signature

If participant is unable to consent independently:

Authorized Representative's Name

Relationship to Participant