i\PP[:NDIX I: SAN4PLE CONSE,NT FORM TO PARTICIPATE IN RESEARCH

t o.f'
Corr.sent ntust he obtained-fiofi anys7y6t1, participcutt. Written consent.fbnt$ nn$lJollr.tv, tlte -f'ot'ttrct
tlri.s templute, inclu.ding tlte "l understand" forrnat, (exceptions tnay be givetx to tnulti-irtstitutiortal
pro.jects).Ot'alconsentsctiptsshouldincludethescnteinJbrntation.Pleaseadaptthistentplateto.tuit
ltottr prtt ject. La nguage sltould be at no nlote tlt cut n grade eigltt reoding level. If _you a r e s i n g vr: t'i tte n
u

c'ort.sent.fbrnls, note thatparticipants shouldbe given two copieso.f the consentfortn - one to keep, urtd
one lo sigtt cutd retLtrn lo lhe researcher.

CONSENT TO PARTICIPATE IN (RESE,4RCHPROJECT TTTLE)

I Lrl'rderstarldthatlhavebeenaskedtoparticipateinaresearchproject being conducted by (Name o.f

I?esearc'her) of (ltlante o_l-Departnrcrrt) of Concordia Urriversity (cotttuct infu including phone ancl e-muil).
.9tuLle'ttt inve:;tigcrtor"s shall udd; under tire supervision of (Name of'Facultv strpervi.roil of (Nante tt/'
De'ptt rtrrrcnl;oiConcot'dia Urtiversrty (cortac:t irt.fo irtc'lutling pltone ant{ e-moil).

A. PURPOSE
I liave been informed that the purpose of the research is as follor.vs . . . (Please s tate tlt e p Lt r pos e o./' t h e
resettt'c:h clettrlt, atal conciseb,, itt no ntore thcttt one or two sentences).

B. PITOCEDURES
Irr corr.si:-letrl, "J urtderstand"-fbrtnat, please indicate in this section wlrcre the researclt vvill lte contlucted
and tlesc'ribe in tton-technical terrns u,hat the participrmtsrrill be a.sked to do, the tinrc recluired to do it,
oncl art.\,,.spccinl.so./bguards being talcen lo prolect tlle con-fidentialit.tt ot'u,ell beingo.f the pttrticipctnt.r.

C. ITISKS AND BENEFITS

Itr cctrt.ristettl, "l understcutd".fbrmctt,pleaseindicatein this sectiotl all potentinl risks ofpctt'tic'iltcrtiott.
tt nrl o rt.y b enefit.s oJ' p nnic ipa ttott.

D. CONDITIONS OF PARTICIPATION

. . I understand that I am free to r,vithdraw my consent and discontinue my participation at arty'time

rvi tho Lrt negative consequences.

I understarrd that my participation in this sftrdy is Qtick appropriate v,ord)

CONFIDENTIAL (i.e., the researcher will know, but rvill not disclose my identiry)
oR
NON-CONFIDENTIAL (i.e., r:ry identity will be revealed in srudy results)

I understand that the data frorn this study niay be published.

OR
i understand that the data from this snrdy will rrot be published.

I HAVE CAREFULLY STUDIED THEABOVEAT"\D UNDERSTAND THIS AGREEMENT. I

FREELY CONSENT AND VOLUNTARILY AGREE TO PARTICIPATE IN THIS STUDY.

OOR Abbrevioted Suntnrur), Prot<tc'ol Form (20 I 4l

 Francisco Azares
NAi\4E (please prirrt)

SICNA"IURE

If at any tinre you have questions about the proposed research, please contact the stlldy's Principal
lnvestigator
lntlicute in this sectiortthe name, Depurtntent arulcontact infonnatictn.fur the Principal lnt'estigator.
Studant irtvastigcttot's shall atkl; or (Nante of Faculiy- supervisor) of (l/arne o.f Department) of Concordia
U rr i v ers ity (c: o tt tac' t i tt fo i nc I ud i rtg p lt on e a t d e - mai l).
t

Ifat any tiure you have questions about yor"rr rights as a research participant, please contact [he Manage r,
Research Ethics, Concordia Uruversitv, 514.848.2424 ex.7481 oor.ethics(irtcolcotdia.ca

OOR Abltrevittted Suntmaq, Ptotot'ol Forn 120l 41