Nan,c: ... .. . . . . . .. . . . . . . . . .... . .. .. . . .. . . . . . . . . . . . . . .. .. . . ... . . . .. . . . .. . . . . .........

(Optional)

.Gen<.ler:. ..... ... .. ......................... •

Educational Qualilica1ion:............. .. ... . .... ...... .. .... .. ............... ..... ••••.. ······..

Informed Consent
This is to certify that, 1 ........!, .. .'................................. .. ....................·..... , hereby agree to participate •as a
volunteer in an investigation (experiment, program, practical) as an authorized part of the academic
activity under the supervision of ........:... ........................_. .............................................................................. .
7
The investigation and my part in the investigation have been defined and fully explained to me by
···············:········.. ····• ....._. ..........................................._. ... ,and I understand his/her explanation.
I have been given the opportunity to ask whatever questions I may have had and all such questions
and inquiries have been answered to my satisfactions. ·

I understand that that I am free to deny any answers to specific items or questions in interview or
questionnaire.

I understand that the data and answers to the questions wlll be kept confidential with regards to my
identity. I also understand that the data and answers are only for academic purposes. I understand
that by participating in the investigation there will not be any effects on my physical, social, cultural,
spiritual, psychological, and religious and belief system.

I also understand that I will not receive any remuneration 'for my participation in the investigation.

I certify that to the best of my knowledge and belief, I have no physical and mental Illness or weakness
that would increase the risk of my participation of this Investigation.

I further understand that I am free to withdraw my consent and terminate my participation any time.

Date: Signature bf the Participant

: ,.
Place: Name of the Participant

'1' ' 1
Date: Signature of the Investigator
I •
Pia~ Name of th~ Investigator
11

1ntuction~
'
t. You must select one of the two statements.
!2. Both the options are equally correct.
3. Please choose fih:e respo~se that you ~ould most likely ~se, even though neither the
"A" nor the 11 9!t ·statemcm is very typical of your behavior.
4. The test has no set time-limit.
I