ASSENT FORM FOR CHILDREN AGED 7-18 YEARS

Protocol / Study number:______________________

Participant identification number for this trial: _______________________

Study Title: Comparison of efficacy between suggestion method during video EEG

recording by verbal suggestion in isolation and verbal suggestion along with cotton swab or

tuning fork for inducing the paroxysmal event in children aged 5 to 18 years with suspected

psychogenic nonepileptic events

Name of Principal Investigator: Professor Sheffali Gulati, Chief Pediatric neurology; Department
of Pediatrics, AIIMS, New Delhi

The contents of the information sheet dated………., that was provided have been read carefully
by me / explained in detail to me, in a language that I comprehend, and I have fully understood
the contents. I confirm that I have had the opportunity to ask questions. I understand that my
participation in the study is entirely voluntary and I have also been informed that I can withdraw
from the study at any time without losing on any benefits/treatment.

I agree to take part in the above study.

--------------------------------------------- Date:
(Signatures) Place:
Name of the Participant: ____________________________________
Son / Daughter / Spouse of:__________________________________
Complete postal address: _____________________________________

Signature/Thumb Impression of the Legal Acceptable Representative(LAR): ------------------------

This is to certify that the above consent has been obtained in my presence.
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Signatures of the Principal Investigator Date:
Place:
1) Witness – 1 2) Witness – 2
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Signatures Signatures
Name: Name:
Address: Address: