SELF CONSENT

For Official Use Only
Date received:
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SELF CONSENT

I have been invited to take part in a research study titled:                               

This study is being conducted by                               , who can be contacted at:

I understand that my participation is voluntary and that I can refuse to participate or stop taking part any time without giving any reason and without facing any penalty.  Additionally, I have the right to request the return, removal, or destruction of any information relating to me or my participation.

PURPOSE OF STUDY

I understand that the purpose of the study is to: to describe the impact of chronic pain on the patient and the people around them. Also, I will determine how the patients handle chronic pain by themselves.

PROCEDURES

I understand that if I volunteer to take part in this study, I will be asked to conduct observation and interviews with participants, recording the participants pain management procedures

BENEFITS

I understand that the benefits I may gain from participation include: None other than partial fulfillment for the course grade for the NSG6101

RISKS

I understand that the risks, discomforts, or stresses I may face during participation include:

No risks are involved in participating in this study.

CONFIDENTIALITY

I understand that the only people who will know that I am a research subject are members of the research team.  No individually-identifiable information about me, or provided by me during the study will be shared with others except when necessary to protect the rights and welfare of myself and others (for example, if I am injured and need emergency care, if the provided information concerns suicide, homicide, or child abuse, or if revealing the information is required by law).

FURTHER QUESTIONS

I understand that any further questions that I have, now or during the course of the study can be directed to the researcher (                                                           ).

Additionally, I understand that questions or problems regarding my rights as a research participant can be addressed to Dr. Jessica Hillyer, Institutional Review Board Director of Compliance and Training, South University, 7700 W. Parmer Ln., Austin, TX 78729;

My signature below indicates that the researchers have satisfactorily answered all of my current questions about this study and that I understand the purpose, procedures, benefits, and risks described above.  I have also been offered a copy of this form to keep for my own records.

Participant Printed Name

Signature of Participant                                                                                 Date (mm/dd/yyyy)

Signature of Principal Investigator                                                            Date (mm/dd/yyyy)