77





26. SIgnalares

 As a representative of ihis sudy, have explained lo ihe participant the pupose. Ihe
 procedures, the possible bent fit, and Ihe risks or ihis rcarch sludy. ihe all'm.nitcs to being
 in iliSe tuil, and how Ihc parieipail's protected health information will be collected, used, and
 disclosed:




 Signaiiun or Person Obtaining Consent and Authorizaion Date



 You have been infonned about this sludy's ptupse, procedures, possibLo bmeielt, and risks;
 ihe attemntves to being in the sludy, and ihow vyor prniecied ]i llh informilion will be
 ;oll]ccid, used and disclosed. You have received a copy ofthis Form. You have been given
 ilt; opponuilly l Io ak qurslionrs be re[ n siln. and you hjae been iold imwr you can ask other
 questions at ant iime

 You voluntarily agr i io pirniCipai in ihis study. You liheby auiuhorir c Lhc icolcciion. us aid
 disclosuir of your protected halth inromalion as described in sections 15-24 above. By
 signing dl.s, J rin, you are nol waiving any afPaur Icgl nJghtl,




 Signalure of Person Consenling and Authorizing Dale


250M2003 Rev 06-14-1 f Pa 7 of7