26. Signatures

 As a representative of Uis study, I hIve explained to the participant the pLurpse, the
 procedures, Ihe possible bir fisL. and Ihe risks of this research study; Ihi alternatives to being
 ini the 51udy. and how the participant's protected health infoTmaton will be collected, usel, and
 disclosed:




 Si griauur of Peron ObLt ning CoInsIe ani Aulhon-alon Dale



 You have been informed about this study'spurposc procedures. poaible benefit, anr nskst.
 theallcnalivcs [o being in Lh2 sNudy. and howv your potected health information will be
 collocietd. used and disclosed. You have received a copy of this Fonm You have been given
 lthe opportunity lo ask questions bclirc you sign. and you have been told that you can ask other
 questions ai any line.

 'ou volunU~rily agree to palicipalt in this study. You hrreb" .uuLhori.h the .lkction, use and
 disclosure oryour prolecled health information as described in sections 15-24 above. By
 signing this ronrm you are not waiving any o your legal rights.


Signature ofPcrson Consenting and Aullhorizing


Dale


25900W IRcrv o1-27-04 / Pag 7 of 7