Informed Consent Form

Title of Study:

Principal Investigator:

Purpose of the Study

Procedures

Risks and Discomforts

Benefits

Confidentiality

Voluntary Participation

Contact Information

Consent

I have read and understood the information above. All of my questions have been answered. I agree to participate in this study.

Participant Name:

Date:

Participant Signature:

Investigator Signature (if applicable):