IRB Number : IRD_IRB_20__

PI : xxxxxxxxxxxxxx
PI version Date : Dec 31, 2016

Study Title:
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Assalamoalikum

My name is Dr. Annum Ishtiaq; I am from Family Medicine Department of Indus Hospital. I am
conducting a study in which we are looking for degree of Liver affected in Chronic Hepatitis C
patients , We will be able to do so by help of blood tests in all Hepatitis C patients and we might
get a special type of Liver ultrasound ( transient Elastography ) done in few patients . This
study is done to estimate the severity of liver fibrosis and help us guide in treatment of hepatitis
C. if you agree to be a part of this study, we would like to ask few questions that will take five
minutes of your time. We are inviting all patients enrolled in hepatitis C program to be a part of
this study,

Privacy: We assure you that your research information will be kept secret. We will use ID
numbers instead of your name. Your name will not be given to anyone without your consent. It is
possible that research papers may be published for scientific purposes; however your name nor
that of any other participant will not be used.

Your participation is voluntary. You can decline to participate, and you can stop your
participation at any time, if you wish to do so, without any negative consequences to you.

By you answering the survey/interview questions that I will ask, this means you consent to
participate in this research project. Do you have any questions?

Do you agree to be part of this research?

Patient agrees to be part of this study and I have given them an opportunity to answer queries:

Sign of person taking consent: ___________________ Date: _________________

Cut and give to patient who consents

You have consented to be part of this research study. If you have questions about this research, you may
contact Dr. xxxxxxx at this number (xxxxXXXXX) at Indus Hospital.
If you have questions about your rights in a research study as a volunteer, call or contact the Interactive
Research & Development-IRB office between office hours on Monday to Friday 9am 5pm at the Indus
Hospital