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Local Media473094490703321251
Local Media473094490703321251
4. Statement of Confidentiality:
Your participant in this research is confidential. Only members of the
research team will have access to the associated with this study. The data will be
stored and secured at the investigator’s office in a locked cabinet/password
protected computer.
Any information that is in connection with this study and that is identified
with you will remain confidential and will be disclosed only with your permission or
a required by law. When the result of the research is published or discussed in
conferences, no information will be conducted that would reveal your identity.
If you agree to take part in this research study and the information outlined
above, please sign your name and indicate the date below.
A copy from this form will be given to you for your records.
_____________________________
Name of the participant Thumb mark if participant cannot write
_____________________________ ______________________
Signature of the Participant Date
(If the participant, register his/her consent by thumb mark, there will be a witness, who
will also sign as a witness. The student-researcher cannot serve as a witness)
_________________________ ___________________
Name and Signature Date
( ) I am willing to have the interview documented but photo shots are silhouette
or the back portion only
_________________________ ___________________
Name and Signature Date
Page 4 of 4
I have explained the research to the subject and answered all his/her
questions. I believe that he/she understands the information described in the
document and freely consents to participate.
______________________________________________ __________________
Name Signature of the Student-researcher Date