APPENDIX - 5

INFORMED CONSENT FORM

I understand that I am being asked to participate in a research study in

________________________________, ____________. The Purpose of this study
is to ______________________________________, thereby_________________.
The procedure of this study has been clearly explained to me. I realize
that I may not participate in the study if I do not satisfy the selection criteria. I
understand that my participation in this research study is entirely voluntary. I
acknowledge that I have the right to question any part of the procedure and can
withdraw at any time without this being held against me.
I understand that the information obtained from this research study is
strictly confidential. I acknowledge that results of this study may be used in future
research and may be published, provided that my personal details will not be
revealed.
If I have any questions regarding this research study, I understand that I
may contact _______________________ anytime during the study.

All my questions have been answered, and I agree to participate in the study.

Date:

Signature of the participant

Signature of the investigator

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