Informed Consent

The general nature of this project entitled " Improving Organ Donor Eligibility through
Protocol-directed Medical Management in a Low Resource Setting " conducted by the researchers
has been explained to us. We understand that we need to consent for a new medical management
towards our patient. Our participation in this project will last for the entire treatment management
of our patient. I understand that our approval will be confidential or that my patient’s anonymity
will be preserved. Outputs will be known to the researcher but will not be divulged and that our
patients name will not be associated with any results of this project. I know that we may refuse
and that we may discontinue participation at any time. We also understand that we will not receive
any amount as payment for participation. We understand that there would be potential risks during
our participation and this project have been explained and described to us. We are aware that we
may report dissatisfactions with any aspect of this research to the Institutional Review Board for
the Protection of Human Participants. Our decision below signifies our voluntary participation in
this project, and that we have received a copy of this consent form. Questions about this project
may be obtained by contacting one of the group researchers, Dr May Anne Plarisan with mobile
phone number: (082) 227-2731 local 4125.
o Agree
o Disagree

Statement by the Researcher/Person Taking Consent:

I have accurately read out the information sheet to the potential participant, and to the best
of my ability made sure that the family members understands that the following will be done:

 The participation of the participants is voluntary.

 All gathered data will be limited to the use of this study.
 All files will be kept confidential in the secure possession of the researcher.
 The participant may withdraw from the study at any time with no adverse repercussions.
 The participant can contact the researcher if there are any questions or concerns regarding
the conduct of the study.

I confirm that the participant was given an opportunity to ask questions about the study,
and all the questions asked by the participant have been answered correctly and to the best of my
ability. I confirm that the individual has not been coerced into giving consent, and the consent has
been given freely and voluntarily. A copy of this Informed Consent Form has been provided to the
participant.

Name of Researcher/person taking the consent _________________________

Signature of Researcher /person taking the consent _________________________
Date _________________________
Day/month/year

Name of person giving the consent _________________________

Signature of person giving the consent _________________________
Date _________________________
Day/month/year

Witness _________________________
Signature _________________________
Date _________________________
Day/month/year