Document text
Machine-read from the scan, so expect some errors. Lines that couldn’t be read are left out.
Page 1
Dr. Henderson and his associates are doing a research study about the effects of the environment (pollution, work-related exposure t o chemicals, and other substances) on the protein concentration in sperm. The study will include both men with low sperm counts, and normal men with average sperm counts; as I a m one of these 'lnonnal" males, I have been asked t o be a subject.in this study. IfI agree to participate, thc following will happen: d I will fill out a questionnaire with information on my personal and med i cal hi story. I will be asked t o bring in2 sperm specimens, the first one 3to 14 days after my vasectomy counselling visit,and the second one when I corn8 into have my vasectomy operation. be collected by nias tur bati on,in the plastic specimen jar, which will be provided t o me, after3 days of abstinence (no ejaculations). I f possible, the complete spec'imen (ejaculate) should be caught in the ' jar and brought t o the Family Planning Clinic a t SFGH within4 hours. Each sperm specimen should If I bring fn 2 specimens, I will receive $20.00 reimbursement for my extra inconvenience. IfI can bring i n only 1 specimen, I should bring i t with me a t the time o f the operation. I will not be paid for this. Fione of the iiifo,mation from the questionnaire o r from the sperm t e s t s will be linked specifically with my name for purposes o f the study. maintained. In this way my privacy will be There are no known risks to participating in this study, and no direct benefits t o me. Hawever, infotmat-ion from the study may increase knowledge about the environKent and its effects on the male reproductive systen. PP.RTICIPATIOI1 IN THIS RE SEA ii C HIS COMPLETELY VOLUNTARY.I AI4 FREE TO DECLINE TO TAKE PART IN THIS STUDY OR TO WITH DR AN AT ANY TIME, WIT ll OUT AFFECTING M Y STATUS OR CARE AT THIS CLINIC. ' This study has been explained t o my by (Subject'c, sign atc re j