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Consent Fom (pdf) - Noguchi

Consent Fom (pdf) - Noguchi

Notification of

Notification of Significant New Findings (A statement that significant new findings developed during the course of the research that may relate to the participant’s willingness to continue participation will be provided to the participant) (This does not apply to all studies) Contacts for Additional Information (Give an explanation of whom to contact for answers to pertinent questions about the research and whom to contact in case of research-related injury. Give names and mobile numbers that are accessible to the participant) Your rights as a Participant This research has been reviewed and approved by the Institutional Review Board of Noguchi Memorial Institute for Medical Research (NMIMR-IRB). If you have any questions about your rights as a research participant you can contact the IRB Office between the hours of 8am-5pm through the landline 0302916438 or email addresses: nirb@noguchi.mimcom.org or HBaidoo@noguchi.mimcom.org . 2

VOLUNTEER AGREEMENT The above document describing the benefits, risks and procedures for the research title (name of research) has been read and explained to me. I have been given an opportunity to have any questions about the research answered to my satisfaction. I agree to participate as a volunteer. _______________________ _________________________________________________ Date Name and signature or mark of volunteer If volunteers cannot read the form themselves, a witness must sign here: I was present while the benefits, risks and procedures were read to the volunteer. All questions were answered and the volunteer has agreed to take part in the research. _______________________ _________________________________________________ Date Name and signature of witness I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual. _______________________ __________________________________________________ Date Name Signature of Person Who Obtained Consent 3

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