PG THESIS PROTOCOL

A DESCRIPTIVE CROSS SECTIONAL STUDY ON THE

ETIOLOGICAL FACTORS AND MANAGEMENT OF EPISTAXIS IN A
TERTIARY CARE CENTRE

Submitted by,

Dr. Lekshmi Devi V

Junior resident

Department of Otorhinolaryngology

Sree Uthradom Thirunal Academy of Medical science Thiruvananthapuram

Ph: 7559921014

Email ID: lekshmigsv@gmail.com

From,

Dr. Lekshmi Devi V

Junior Resident

Department of Otorhinolaryngology

Sree Uthradom Thirunal Academy of Medical Science, Thiruvananthapuram

To,

The Secretary

Institutional Research Committee

Sree Uthradom Thirunal Academy of Medical Science, Thiruvananthapuram

Through proper channel

Subject: Application for Institutional Research Committee Approval

Respected Sir / Madam,

I am a postgraduate student in the Department of Otorhinolaryngology, Sree

Uthradom Thirunal Academy of Medical Science Thiruvananthapuram. I have joined the
course on 24/11/2022. I am planning to do my thesis entitled "A DESCRIPTIVE CROSS
SECTIONAL STUDY ON THE ETIOLOGICAL FACTORS AND MANAGEMENT
OF EPISTAXIS IN A TERTIARY CARE CENTRE". Kindly grant me permission to
pursue the same.

Thanking You,

Yours faithfully,

Dr. Lekshmi Devi V

Junior Resident
Department of Otorhinolaryngology
Place: Thiruvananthapuram Sree Uthradom Thirunal Academy of
Date: Medical Science, Thiruvananthapuram
DECLARATION BY THE GUIDE

Name of PG Student: Dr. Lekshmi Devi. V

Department: Otorhinolaryngology

Title of the Study: A descriptive cross sectional study on the etiological factors and

management of epistaxis in a tertiary care centre

I take the full responsibility and accountability for planning, execution, and adverse events

occurring during the study .The data collected and records will be retained by myself for a

period of three years. .

Signature of Guide (Name and Designation of guide, seal, date)

GENERAL INFORMATION

1. Title of the proposal: A DESCRIPTIVE CROSS SECTIONAL STUDY ON THE

ETIOLOGICAL FACTORS AND MANAGEMENT OF EPISTAXIS IN A

TERTIARY CARE CENTRE

2. Name of the PG student: Dr. Lekshmi Devi. V

Phone No: 7559921014

Email id: lekshmigsv@gmail.com

3. Name of the course of study: MS Otorhinolaryngology

Institute - Sree Uthradom Thirunal Academy of Medical Science

4. Month and year of appearing in final examination for completing the course: 2025

5. Name(s) ,designations(s) & address of guide and co-guide (s) with mobile number and

Email ID

Name of Guide: Dr Swapna U P

Professor & HOD of ENT

Sree Uthradom Thirunal Academy of Medical Science

Mob No: 9747166535

Email id: swapnamanoj@gmail.com :

Name of Co- Guide: Dr. Smitha B

Assistant Professor

Department of ENT
 Sree Uthradom Thirunal Academy of Medical Science,

Mob No: 9447961555

Email id: smitha.arun@gamil.com

6. State whether it is intradepartmental or interdepartmental: Intradepartmental

Signature of PG student

Signature of Guide Signature of Co-Guide

Signature of Head of the Institution (with seal)

INTRODUCTION

Epistaxis is defined as bleeding from the nose. It is one of otolaryngology’s

commonest and most difficult to treat emergencies 1. Approximately 60% of population are

affected by epistaxis at some point in their lifetime, with 6% requiring medical attention 2. It

affects all age groups and both sexes. Epistaxis can be classified as anterior and posterior

based on the site of origin 3. Anterior epistaxis is more common than posterior epistaxis 4.

Anterior epistaxis arises either from Kiesselbach’s plexus, a rich vascular anastomotic area

formed by end arteries in Little’s area or from retrocolumellar vein. It is more common in

children and young adults. It is rarely severe and can be controlled by local pressure or

anterior nasal packing. Posterior epistaxis arises commonly from Woodruff’s plexus, a plexus

of prominent blood vessels lying just inferior to the posterior end of inferior turbinate 5 . It is

more common in elderly. Usually the bleeding will be profuse and requires posterior nasal

packing or arterial ligation 6.

The causes of epistaxis can be divided into local, general systemic, medication induced.

The local causes includes: infection, trauma, deviated nasal septum, septal spur , digital

manipulation , foreign body , chemicals , neoplasm , etc. The general systemic causes

includes: hypertension, arteriosclerosis, coagulopathies, liver cirrhosis, nephritis, etc .

Medications causing epistaxis includes: NSAIDs, Anticoagulants, topical nasal steriods etc .

If no cause is detected clinically and after investigations, it is classified as idiopathic.

For the effective management of patients with epistaxis, it is important to know the blood

supply of nasal cavity. Nasal cavity is supplied by branches of internal and external carotid

arteries. Majority of the nasal cavity is supplied by the sphenopalatine artery, which is a

branch of external carotid artery.

 Most of the cases can be treated successfully with conservative treatment modalities like

general first aid, chemical cauterization , anterior and posterior nasal packing . In cases of

refractory epistaxis, surgical intervention such as ligation techniques, septal surgery,

embolization, can be considered 7

REVIEW OF LITERATURE

Literature search was done and the role of identification of different aetiological factors for

the effective treatment of epistaxis were reviewed.

A study was conducted by Ramesh Parajuli in 2015 among 84 patients with epistaxis in a

tertiary care hospital in central Nepal. Out of 84 patients, 52 were males and 32 were females.

The most common cause of epistaxis was idiopathic (38.09%) followed by hypertension

(27.38%), trauma (15.47%) and coagulopathy (8.33%). Regarding treatment methods, most

(52.38%) of patient required anterior nasal packing. Chemical cautery was sufficient to stop

bleeding in 14.28% of patients; electrocautery and posterior nasal packing were performed in

2.38% and 16.66% patients. Two patients (2.38%) required endoscopic sphenopalatine

arterial ligation. Anterior nasal packing was the most common treatment method used for

majority of the patients 8.

A study conducted by Sampigethaya S et al (2018) among 60 patients presenting with

epistaxis in a tertiary care hospital Mangalore. Out of these 65% were males and 35% were

females. Most of the cases were aged more than 50 years (31.7%) with the mean age of 38.56

years. Most common aetiology of epistaxis in this study was hypertension (20%), followed

by acute rhino sinusitis (15%). Commonest cause in children was deviated nasal septum and

acute rhino sinusitis, while in young adults trauma was the most common cause. Most

common cause in elderly was hypertension. Medical management was given in most of the

cases (65%) while anterior and posterior nasal packing was done in 20% and 10% cases
respectively. Three cases underwent electro cauterization of bleeding point 9.

A retrospective study was conducted by Shweta (2019) among 96 patients with epistaxis in a

tertiary care hospital Himachal Pradesh. Out of the total 96 cases, 58.3% were males and

41.6% were females. Most of the patients were over 40 years of age. The maximum,

19(19.79) were in the age group of 51-60 years and minimum 2 (2.08%) were in the age

group of 90-100 years. In the study of 96 cases , common group in this series was of

cardiovascular causes (hypertension , arteriosclerosis, on antiplatelet drugs ) , out of 59 cases

(61.45%) 9 patients were on antiplatelet drugs followed by idiopathic cases 13 (13.54%) ,

trauma 12 (12.5%) , 7 cases (7.29) had blood dyscrasias , DNS with spur in 3 (3.12%) ,

infection in 1 (1.04%) , alcoholic liver disease in 1 (1,04%) . Out of 96 cases, 92 cases

(95.8%) responded to non-surgical methods 10 .

AIMS AND OBJECTIVES

1.To identify the cause of epistaxis in different age groups

2.To identify the age group in which epistaxis is more prevalent.

3.Effective management of epistaxis on the basis of etiology.

METHODOLOGY

Research question: How far the identification of aetiological factors help in the effective

management of people with epistaxis.

Study design: Hospital based descriptive Cross Sectional Study

Duration of study: 2 year after Institutional Research Committee and Ethical Committee

approval.
Study setting: Department of Otorhinolaryngology, Sree Uthradom Thirunal Academy of

Medical Science, Thiruvananthapuram

Study Period: 2 year

Sample size: 94

Calculated using the equation

n= Zα 2 p q /d2

p = 27.4, q = 72.6, Zα=1.96, d =9

n = (1.962 x 27.4 x 72.6) / 92 = 94 patients

Sampling Method: Convenient sampling

Study population: Patients with epistaxis attending to the outpatient department of

otorhinolaryngology and casuality of Sree Uthradom Thirunal Academy of Medical Science,

Thiruvananthapuram during the study period.

Inclusion criteria

1. Patients presenting with epistaxis in the out patients and emergency department of

ENT in the age group of 0 to 80 years who gives consent for the study

Exclusion criteria

1. Patients not willing to participate in the study.

2. Patient with Altered mental status.

3. Post-operative epistaxis after surgeries like septoplasty and FESS.

4.Patients >80 years age

Study variable: Independent variables are age, sex, and the dependent variables are imaging

study and nasal endoscopic findings.

Method of data collection and study procedure

An informed consent will be obtained from the patients and parents of children in the study

population. The first priority will be given to arrest the bleeding by first aid measures or

anterior nasal packing. Then a detailed medical and surgical history will be taken. This will

be followed by general and detailed otorhinolaryngological examination. The nose

examination will include anterior rhinoscopy using Thudicum or Killian’s nasal speculum

and posterior rhinoscopy using St. Clair Thompson’s postnasal mirror. Complete blood

examination will also be carried out in order to rule out systemic causes and

coagulopathies .Nasal endoscopy will be performed if no definite cause is detected by above-

mentioned clinical examination. Radiological evaluation includes Xray paranasal sinuses, CT

scan nose, paranasal sinuses and nasopharynx or MRI scan.

Study tool

1. Nasal speculum

2. Rigid / Flexible endoscopy

3.A predesigned and preassessed structured proforma

DATA ENTRY AND STATISTICAL ANALYSIS

Data obtained will be entered in Microsoft office excel sheet. Statistical analysis will be done

with the help of SPSS version 27. Categorical variables will be expressed in frequency and

percentage. Continuous variables will be expressed as mean and standard deviation.

ETHICAL CONSIDERATION

Study will be conducted only after getting approval from the ethical committee of the

institution and KUHS. Written informed consent will be obtained from all the patients. When

the subject is younger than 18years, written informed consent will be obtained from their

parents. Privacy and confidentiality will be maintained. Study results will be used only for

scientific purposes and publications.

OUTCOME OF THE STUDY

The expected outcome of the study is to find out how identification of aetiological factors

will help in the effective management of people with epistaxis.

REFERENCES

1. John C Watkinson , Raymond W Clarke. ''Epistaxis'' Chapter - 106 , Scott - Brown's

Otorhinolaryngology Head and Neck Surgery 8th edition ; volume 1 ; pp 1169 .

2. M. Small , J.A.Murray, and A.G.Maran , “A study of patients with epistaxis requiring

admission to hospital” Health Bulletin , Vol. 40 , no.1 , pp.20-29,1982.

View at : Google Scholar.

3. T.W.M.Walker, T.V.MacFarlane, and G.W.McGarry, “The epidemiology and

chronobiology of epistaxis: an investigation of Scottish hospital admissions 1995-2004”,

Clinical Otolaryngology , vol.32 , no.5 , pp.361-365 , 2007.

4. S.H.Ciaran and H. Owain, “Update on management of epistaxis”, West London Medical

Journal, vol.1 , pp. 33-41 , 2009.

5. John C Watkinson , Raymond W Clarke. ''Epistaxis'' Chapter - 106 , Scott - Brown's

Otorhinolaryngology Head and Neck Surgery 8th edition ; volume 1 ; pp 1170

6. D.A.Klotz , M.R.Winkle , J.Richmon , and A.S.Hengerer , “ Surgical management of

posterior epistaxis : a changing paradigm” , Laryngoscope , vol.112 , no.9 , pp. 1577-

1582,2002.

7. John C Watkinson , Raymond W Clarke. ''Epistaxis'' Chapter - 106 , Scott - Brown's

Otorhinolaryngology Head and Neck Surgery 8th edition ; volume 1 ; pp 1177

8. Parajuli. R. “ Evaluation of aetiology and treatment methods for epistaxis : A review at a

tertiary care hospital in central Nepal” , Int.J.Otolaryngol.2015.

9. Sawanth Sampigethaya , Elizabeth Cheriyan , Deepika Pratap , Ivan Mani , Vadisha

Srinivas Bhat , “ A clinical study of epistaxis” , Int.J.Otorhinolaryngol Head and Neck

Surg .2018

10. Shaweta , Rajnish Sharma , Nisha Sharma, “ Epistaxis : A retrospective clinical study”.

Int.J.Otorhinolaryngol Head and Neck Surg.2021 Jul;7(7):1158.

 PROFORMA

● Name:

● Age:

● Sex:

● Occupation:

● Phone no:

● Address:

Presenting complaint

● Bleeding from the nose since:

● Onset:

● Duration:

● Unilateral/bilateral:

● Quantity:

● History of trauma:

● History of upper respiratory infection:

● History of allergy:

● History of similar episodes in the past:

● Having bleeding disorders / taking blood thinners/ hypertension / any regular

medications / other diseases if any:

● History of surgeries in the past:

● History of similar complaints / bleeding disorders in the family:

● Any primary management done at home to control bleeding:

● If yes mention the procedure :

● Any medical / surgical treatment taken for similar complaints in the past:
GENERAL EXAMINATION

● Vitals: BP: pulse:

● Systemic examination:

● Central nervous system:

● Cardiovascular system:

● Respiratory system:

● Gastrointestinal system:

● Ear nose throat examination:

EXTERNAL APPEARANCE

● Cold Spatula Test:

● Vestibule:

● Anterior rhinoscopy:

● Nasal septum:

● Nasal passage:

● Nasal mucosa:

● Floor:

● Lateral wall:

● Deviated nasal septum:

● Posterior rhinoscopy:

● Paranasal sinus tenderness : yes / no

● If yes, specify:
INVESTIGATIONS

● BRE

● BT

● CT

● PT INR

● APTT

● RFT

● LFT

● BLOOD GROUP

● PERIPHERAL SMEAR

● NASAL ENDOSCOPY

● ANY OTHER INVESTIGATIONS

● TREATMENT GIVEN
 PATIENT INFORMATION SHEET

I, Dr. Lekshmi Devi .V, postgraduate student in the Department of Otorhinolaryngology at

Sree Uthradom Thirunal Academy of Medical Sciences, Trivandrum, is conducting “A

DESCRIPTIVE CROSS SECTIONAL STUDY ON THE ETIOLOGICAL FACTORS AND

MANAGEMENT OF EPISTAXIS IN A TERTIARY CARE CENTRE”. As a part of the

study, I will be doing detailed interview of the patient. By participating in the study, you will

not have to incur any additional expenses. The outcome of the study will be used for

academic purposes and for publishing articles. But the details of the individuals will be kept

confidential. Participating in the study will not result in any harm to the subjects. You can

withdraw from the study at any point of time without any reason, which will not affect your

further treatment in the hospital.

Investigator: Dr. Lekshmi Devi V

First year postgraduate student

Department of Otorhinolaryngology

Sree Uthradom Thirunnal Academy of Medical Sciences, Thiruvananthapuram

 CONSENT FORM

A DESCRIPTIVE CROSS SECTIONAL STUDY ON THE

ETIOLOGICAL FACTORS AND MANAGEMENT OF EPISTAXIS IN A

TERTIARY CARE CENTRE

I have fully read and understood the information given to me by Dr. Lekshmi Devi .V. I am

adequately informed about various aspects of the study. I am aware that I have the right to

withdraw from this study at any time and it will not affect my treatment at any cost. I

understood that there is no financial liability on me. I understood that result of the study will

be published maintaining the patient confidentiality

I the undersigned, give my consent to be a participant of this

study.

Signature of patient: Signature of witness

Name : Name:

Address and PhoneNo: Address and PhoneNo:

Relative's Approval (in the event if the patient is under aged / cannot comprehend and

consent )

I (Relative / Guardian) of

have fully read and understood the information given to me by Dr.Lekshmi Devi .V. I am

adequately informed about various aspects of the study. I have understood that i have the

right to refuse the consent or withdraw it at any time during the study without adversely

affecting my ward's treatment. I understood that there is no financial liability on me. I

understood that the result of the study will be published maintaining the patient

confidentiality. I undersigned, give my consent to be a participant of this study.

Place: Signature/Thumb impression:

Date: Name of relative/guardian:

 സമ്മതപത്രം

എസ്‌. യു. ടി അക്കാദമി ഓഫ് മെഡിക്കൽ സയന്സിലെ ഇ.എൻ.ടി വിഭാഗം പി ജി

വിദ്യാർത്ഥിനി ഡോക്ടർ ലക്ഷ്മി ദേവി. വി ഗവേഷണ പ്രബന്ധത്തിന്റെ ഭാഗമായി എന്നിൽ നിന്നും

ശേഖരിക്കുന്ന വിവരം ഉപയോഗിക്കാൻ സമ്മതം നൽകുന്നു.ഈ പഠനത്തിന്റെ ഭാഗമായി യാതൊരു

വിധ മരുന്നിനോ മറ്റു ചികിത്സക്കോ വിധേയമാകില്ല എന്ന് എനിക്ക്

പൂർണമായുംബോധ്യപ്പെട്ടിരുന്നു. ഇതിനായി എന്റെ മേൽ യാതൊരു സാമ്പത്തിക ബാധ്യതയും

ഉണ്ടാകില്ലെന്നും മനസിലാക്കുന്നു. രോഗിയെ കുറിച്ചുള്ള വിവരങ്ങൾ പൂർണമായും രഹസ്യമായി

സൂക്ഷിക്കുമെന്നും ഡോക്ടർ ഉറപ്പു നൽകിയിട്ടുണ്ട്. മേൽ പറഞ്ഞ പഠനത്തിൽ നിന്നും കാരണത്തെ

അറിയിക്കാതെ പിന്മാറാനുള്ള അവകാശം എനിക്കുണ്ടെന്നും അത് മൂലം എനിക്ക് ആശുപത്രിയിൽ

നിന്ന് ലഭിക്കുന്ന ചികിത്സയിൽ യാതൊരു കുറവും ഉണ്ടാകില്ലെന്നും മനസിലാകുന്നു. ഈ

വിവരങ്ങൾ ശാസ്ത്ര പ്രബന്ധങ്ങളിൽ പ്രസിദ്ധീകരിക്കാൻ എനിക്ക് പൂർണ സമ്മതമാണ്

എന്ന്
 ഗവേഷക :

ഡോ: ലക്ഷ്മി ദേവി വി

ജൂനിയർ റസിഡന്റ്

ഇ.എൻ.ടി വിഭാഗം

എസ്. യു. ടി അക്കാദമി ഓഫ്

മെഡിക്കൽസയൻസ്, തിരുവനന്തപുരം

ഫോൺ നമ്പർ :7559921014

ഒപ്പ്:

രോഗിയുടെ പേര്:

ഒപ്പ്:

ബന്ധുവിന്റെ പേര്:

ഒപ്പ്:

INFORMED ASSENT FORM

Dr Lekshmi Devi V
PG resident

Department of ENT

Sree Uthradom Thirunal Academy Of Medical Science

The informed assent form has two parts

1} Information sheet (gives you information about the study

2} Certificate of assent {this is where you sign if you agree to participate)

You will be given a copy of the full informed assent form

PART-1 : INFORMATION SHEET

My name is Dr.Lekshmi Devi V . I am a junior resident in department of ENT at Sree

Uthradom Thirunal Academy of Medical Science, Thiruvananthapuram. I am

planning to do a cross sectional study on “the etiological factors and management of

epistaxis in a tertiary care centre

”. I am going to give you information and invite you to be a part of the research study. You

can choose whether or not to participate in this. We have discussed the research with

your parents/guardian and they knew that we are also asking you for your

agreement. If you are going to participate in the research, your parents/guardians

also have to agree. But if you don’t wish to take part in the research, you do not

have to, even if your parents have agreed. You may discuss anything this with your

parents or friends or anyone else you feel comfortable talking to. You can decide

whether to participate or not after you have discussed it over. You don’t have to

decide immediately. There may be some words you don’t understand or things that
 you want me to explain more about . Please ask me to stop at any time and i will

explain them slowly. If you decide not to be in this research it is okay and nothing

changes. Even if you say yes you can change your mind later if you feel otherwise

and it’s still okay.

After you say yes to the study, relevant history will be taken from your

parents/guardians ,You can ask me to explain again at any time and I will explain

more about the process. I have checked with the child and they understood the

procedures. This study is not going to cause any harm to you as I am just collecting

some data of you and is not giving you any new drug/vaccine or is not altering your

clinical treatment. I have checked with the child and they understood the benefits.

We will not tell other people that you are in this research and we won’t share

information about you to anyone. Afterwards I will publish them by writing but

keeping your details confidential. No one will be mad /disappointed with you. If you

say no it's your choice. You can think about it and tell me later. If you want you can

say yes now and can change your mind later and it’s still ok. You can ask me

questions now or later. I have written a number and address where you can reach me

or if you are nearby you can come with your parents and see me. If you choose to be

a part of this study I will also give you a copy of this paper to keep for yourself.

PART 2: CERTIFICATE OF ASSENT

I have read this information (or had the information read to me. I have had my questions

answered and I know that I can ask questions later if I want. I agree to take part in

this research. OR I do not wish to take part in this research and I have not signed

the assent below.

Only if child assents

Name of the child................. Signature...............

Date.................

In case of illiterate, I have witnessed the accurate reading of the assent form to the child and

the individual has had the opportunity to ask questions. I confirm that the individual

has given consent freely.

Name of witness.............. Signature..........

Date..........

I have accurately read or witnessed the accurate reading of the assent form to the potential

participant, and the individual has had the opportunity to ask questions. I confirm

that the individual has given assent freely.

Name of Researcher : Signature of Researcher:

Date:

കുട്ടികൾക്കുള്ള അറിയിപ്പോടു കൂടിയുള്ള സമ്മതപത്രം

ഡോക്ടർ ലക്ഷ്മി ദേവി വി

പിജി റസിഡന്റ്

ഇ ൻ ടി വിഭാഗം

എസ് യു റ്റി മെഡിക്കൽ കോളേജ്

തിരുവനന്തപുരം

ഈ അറിയിപ്പിനു 2 ഭാഗങ്ങൾ ഉണ്ട്

• വിവരണം (ഈ പഠനത്തിന്റെ വിശദാംശങ്ങൾ )

എന്റ്റെ പേര് ലക്ഷ്മി ദേവി വി . ഞാൻ എസ് യു റ്റി മെഡിക്കൽ കാേളജിെല ഇ

ൻ.ടി വിഭാഗത്തിൽ ബിരുദാനന്തര ബിരുദ വിദ്യാർത്ഥിയാണ്. ഞാൻ

മൂക്കിൽ നിന്നുള്ള രക്തസ്രാവത്തെ പറ്റിയുള്ള പഠനം നടത്തുകയാണ് .

ഈ ഗവേഷണത്തിന്റെ വിവരങ്ങൾ നല്കുന്നതിനൊപ്പം ഇതിൻറ്റെ

ഭാഗമാകാനും നിങ്ങളെ ക്ഷണിക്കുന്നു .

ഈ ഗവേഷണത്തെക്കുറിച്ചു നിങ്ങളുടെ മാതാപിതാക്കളെ

അറിയിച്ചിട്ടുണ്ടെന്നും കുട്ടിയുടെ സമ്മതം ഇതിനായി തേടുന്നുണ്ട് എന്നും

അവർക്കു അറിയാം . നിങ്ങൾ ഇതിൽ പങ്കെടുക്കാൻ സമ്മതം അറിയിച്ചാൽ

നിങ്ങളുടെ മാതാപിതാക്കളുടെ സമ്മതവും ആവശ്യമാണ് . മറിച്

മാതാപിതാക്കൾ സമ്മതിച്ചാൽപോലും നിങ്ങളുടെ സമ്മതം ഇല്ലെങ്കിൽ

ഈ പഠനത്തിൽ നിങ്ങൾ പങ്കെടുക്കണം എന്നില്ല .ഇതേപ്പറ്റി നിങ്ങളുടെ

 മാതാപിതാക്കളുമായോ സുഹൃത്തുക്കളുമായോ ചർച്ചചെയ്തശേഷം

തീരുമാനം അറിയിക്കാവുന്നതാണ് . നിങ്ങള് മനസ്സിലാക്കാത്തതു കൂടുതൽ

വിശദീകരണം വേണ്ടതു ആയിട്ടുള്ള കാര്യങ്ങൾ ഉണ്ടെങ്കിൽ ഏതു

സമയത്തും ഞാൻ അത് വിശദീകരിച്ചു തരുന്നതാണ്

നിങ്ങളുടെ അനുമതിക്കുശേഷം അസുഖവുമായി ബന്ധപ്പെട്ട കാര്യങ്ങൾ

മാതാപിതാക്കളിൽ നിന്നും ശേഖരിക്കുന്നതാണ്. ഇതിനാൽ നിങ്ങള്ക്ക്

യാതൊരു ദോഷവും ഉണ്ടാകില്ല. ഈ പഠനത്തിൽ നിന്നും എപ്പോൾ

വേണമെങ്കിലും നിങ്ങള്ക്ക് പിന്മാറാവുന്നതാണ് അതുകാരണം നിങ്ങളുടെ

ചികിത്സായിൽ യാതൊരു കുറവും ഉണ്ടാകില്ല. താങ്കളുടെ

വ്യക്തിപരമായ വിവരങ്ങൾ തികച്ചും രഹസ്യമായി തന്നെ

സൂക്ഷിക്കുന്നതായിരിക്കും. പഠനത്തിന്റ്റെ ഫലം ആവശ്യം വന്നാൽ

പ്രസിദ്ധികരിക്കാൻ സാധ്യതയുണ്ട്.

അറിവോടെയുള്ള സമ്മതം

ഞാൻ ഈ വിവരങ്ങൾ മുഴുവൻ വായിച്ചു (എന്നെ വായിച്ചു കേൾപ്പിച്ചു ).

എന്റെ സംശയങ്ങൾക്ക് എല്ലാം ഉത്തരം കിട്ടി. പിന്നീട എപ്പോൾ

വേണമെങ്കിലും എനിക്ക് ചോദ്യങ്ങൾ ചോദിക്കാനും സംശയം മാറ്റാനും

പാട്ടും എന്നും മനസ്സിലാക്കുന്നു.

ഈ ഗവേഷണത്തിന്റെ ഭാഗമാകാൻ ഞാൻ സമ്മതിക്കുന്നു

അല്ലെങ്കിൽ
ഈ ഗവേഷണത്തിന്റെ ഭാഗമാകാൻ എനിക്ക് സമ്മതമല്ല

പേര്

ഒപ്പ്

തിയതി

നിരക്ഷരർക്കു

ഇതിലെ വിഷാദകാര്യം കുട്ടിയെ വായിച്ചു കേൾപ്പിച്ചതായി ഞാൻ

സാക്ഷ്യപ്പെടുത്തുന്നു. കുട്ടിക്ക് ചോദ്യങ്ങൾ ചോദിക്കാനുള്ള അവസരം

മൽകിയിരുന്നു

സാക്ഷിയുടെപേര് ഒപ്പ്

തിയതി

കുട്ടിയുടെ

കൈയ്യൊപ്പ്