Sample Informed Consent Form Page 2

Statement of DECLARATION:

1. Statements that the participant or his/her legal guardian has read the

informed consent form, or that it has been read to him/her, and that s/he

understands its contents; that a copy will be given to the participant; and

that the signature of the participant or the legal guardian indicates that s/he

has agreed to participate;

2. that time will be given for the participant to consider his or her

involvement

3. Provision of space for an independent witness (not connected to the

research protocol).

Name of Respondent:___________________

Signature of Respondent: ____________________________

DATE:______________________

Name of Researcher:________________________

Signature of Respondent:______________________

Date:______________________

Signature of Independent Witness :_____________________

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Parent category: Legal