Study Title:
Principal Investigator:
1. This
research study is being done:
a.
To make me better
b.
To see if a treatment is safe
c.
To see if a treatment works
2.
Everyone in this study will receive the same
treatment.
True
False
3. One
possible benefit of the research study is that I will be
cured.
True
False
4. One
possible risk of the research study is that I might die.
True
False
5. There
are no other options for my health care.
True
False
6. It
will not cost me anything to be in this study.
True
False
7. If I
do not participate in this research study there are other treatments, drugs, or
things I can do for my illness or condition.
a. There are no alternatives and I have to be in the study to be
treated.
b. I can receive different treatment.
c. I can receive the same treatment even if I am not in the
study.
8.
Participation in this research is voluntary.
True
False
9. If I
decide to participate in this research study, I can change my mind and withdraw
from
the study at any time.
True
False
10. The study doctor and staff and individuals from
the government who are responsible for
being sure that research is done correctly may review my
study records.
True
False