Document text
Machine-read from the scan, so expect some errors. Lines that couldn’t be read are left out.
Page 1
UNIVERSITY OF CALIFOIWIA [name of person(s) who will perform the and/or such assistants as may be selected by him t o perfonn the following procedure(s) and/or investigation,(s) : (Describe in detail in language which will provide a fair explanation of the pro ced urc(s)to be followed, including an id cnt if ica - tion of those which are cxperimental.) 2. The proc cdu rc(s) and/or investigation(s)listed in Paragraph 1
Page 2
described in Paragraph 1. involves (involve) the following possible risks and discomforts: (Describe in detail) and that the possible benefits of the procedure(s) and/or investigation(s) are as follows: '(Describe in detail) and/or such assistant's as may be selected by him will answer any inquiries I may have at any time concerning the pro5 . I understand that I may terminate my participation in the study a t any time, and that, owing to the scientific nature of the ftudy, the investigator may i,n his absolute discretion terminate my participation at any time. In the evcnt that I am being compensgted for my participation
Page 3
and my p nrt ici pati orl is tcrminated by me o r by the in vc stig a torI undcrstand that I will bc entitled to paymcnt of a sum based upon the scientific value to the study of the information obtained from my participation ; providcd, however, that in no event shall I receive less than percent of the agreed compensation ifI continue t o participate beyond the (Describe the applicable time period) (If subject is a minor, o r otherwise unable t o eign, complcto the following): Subject is a minor (age 1 , or i e unable to sign 'because Mother Other person and relationship
Page 4
UNIVERSITY OP CALIFOIWIA CONSENT TO ACT AS IlUEinN SUBJECT Name of Project: I hereby consent to be a participant in the activity named above. An explanation of the procedure (s) and/or inve'stigation (6) to be followed, including an identification of those which are experimental, was provided tome by . I was provided with a ..description of the attendant discomforts and risks to be expected. assured that any inquiries concerning the procedure(s) and/or draw my consent and to discontinue participation in the project: or activity I was assured thatI am free $0 with- (To oral presentation and signature (If subject is a minor or otherwise unable to sign, complete the following) : Subject is a minor (age 1 , or is unable to sign because Ya ther Guardian Mothcr Other pcrson and rc lot io ~ rsl i ip