ࡱ> 463 bjbj *xx         4 @\\\\7"Ym $Z y77yy   \\   y. \ \ y   !E k0 ,d,    `yyy yyyyyyy,yyyyyyyyy* :   Subject Name: ________________________________ On the _____ day of ________,_______ I discussed the possibility of participating in a clinical research trial for Protocol _________________________________________ IRB #:__________________with the above named subject. The study was explained in detail including, but not limited to, the contents of the informed consent, purpose of the study, visits and procedures involved, risks and benefits, alternative treatments, confidentiality, right to withdraw from the study at any time, treatments provided, arms of the study, and randomization. The subject was encouraged to ask questions. All questions were answered to the satisfaction of the subject. The subject was given adequate time to read the informed consent and the opportunity to discuss it. The subject demonstrated understanding of the informed consent and a copy was given to the subject. The informed consent was signed on _____/_____/______ at ______ am/pm prior to any study-related procedures being performed. If the primary language of the adult subject or LAR; or of the child subject or parent/legal guardian is not English: Primary language: ____________________________  FORMCHECKBOX A translator participated in the informed consent interview. OR  FORMCHECKBOX A translator did not participate in the informed consent interview because the person who obtained consent is fluent in both English and the primary language. _______________________________ _______________ Signature of person obtaining consent Date ______________________________ _______________ Signature of PI (if different from above) Date N O = >   * ; > p         ` ȴВВЂzkzchAOJQJjth"[OJQJUhOJQJh!OJQJh3=sOJQJho<ho<OJQJjh"[OJQJUh"[OJQJjh"[OJQJUh!K6OJQJhsOJQJho<OJQJh@OJQJh OJQJhJOJQJhM$OJQJh OJQJ&012   L@& h OJQJho<OJQJh3=sOJQJhAOJQJhmbOJQJ(/ =!"#$% tDeCheck1tDeCheck26~666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66 OJPJQJ_HmH nH sH tH <`< NormalCJ_HmH sH tH DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List RYR  Document Map-D M OJPJQJPK!pO[Content_Types].xmlj0Eжr(΢]yl#!MB;.n̨̽\A1&ҫ QWKvUbOX#&1`RT9<l#$>r `С-;c=1g3=KjK爉ŬʉaqHwo?x}>6!N J?6v?w_Z3tç$y/,YVϲYLcDt~q"9⧣E"g 36AxgKA,Ɖڳ=&-䧘"󷡳<+)/騳2YfEA5i5r{F2rhnz*kU̘aby&Z4MtoKnwu[K@Y5Fm3AM2ޕaŨ; uۭ=: ުv|TV_>%^/*!C!=I.pŭG2#=u{A*?xMVfȯ׆h,"N~e /w$wmBTRUzcn5fwЪtq:nT=q k:V=*^&whv3om <"^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-!pO[Content_Types].xmlPK-!֧6 -_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Atheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]    G G 8@0(  B S  ?Check1Check2hpNO=> ~@"[ !M$!K6o<mb3=sAssl JG@@UnknownG*Ax Times New Roman5Symbol3 *Cx Arial3Times;[xPHelvetica;jMS GothicA$BCambria Math  hWgWgJ'g  !20||PKqHP  $P2!xx /Subject Name: ________________________________Donna HollawayFenderson, Sarah Ashley Oh+'0 4@ d p | '0Subject Name: ________________________________Donna Hollaway Normal.dotmFenderson, Sarah Ashley2Microsoft Macintosh Word@@@t@t ՜.+,0 hp  'UTHSC | 0Subject Name: ________________________________ Title  !"$%&'()*,-./0125Root Entry FE7Data  1Table,WordDocument*SummaryInformation(#DocumentSummaryInformation8+CompObjr  F Microsoft Word 97-2004 Document MSWordDocWord.Document.89q