Informed Consent Form

Community-Based Participatory Research

Title of the Study:

Research Team & Affiliations:

Introduction:

Purpose of the Study

Procedures

Potential Risks & Discomforts

Potential Benefits

Confidentiality

Voluntary Participation & Withdrawal

Compensation

Contact Information

For questions about the study, contact:

Consent

By signing below, you acknowledge that:

• You have read or been read the information above.
• Your questions have been answered.
• You voluntarily agree to participate in this study.