OM t of c.iii - Vision Research Coordinating Center - Washington ...

2/1/99 Chapter 4 Recruitment, Education, Consent page 4-9
15. FINANCIAL INFORMATION
CLEK Study Sample Consent Form
page 3
Participation in this Study will not result in any charges. All Study examinations and
photography will be paid for by the Study. Study participants will receive $20 for each Study
visit as reimbursement for transportation, child care, and other personal costs related to Study
visits.
Regular eye care, including contact lens and/or surgical care, is not paid for by the Study, and is
the responsibility of the Study participant and/or his/her insurance company. The costs of Study
related and unforeseen complications must be met by the Study participant.
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You have been given full opportunity to ask any questions you may have, and all your questions
have been answered to your satisfaction. You have also been given the opportunity to consult
with any person or persons outside ________ Clinic to obtain their opinions and
recommendations.
You have carefully read and fully understand the above statements and hereby consent thereto.
You will be given a signed and dated copy of this form to keep.
Your signature, below, will indicate that you have decided to volunteer as a research subject and
that you have read and understand the information provided above, and the bill of rights.
Date
Signature of Participant or Legal Representative
Date
Signature of Parent if Participant is < 18 Years Old
Date
Signature of Investigator