Title of study:
Participant Information Number:
Please initial the
appropriate boxes
YES NO
1. I confirm that I have read and understood the information sheet for the above study, I have had the opportunity to consider the information and ask questions and have had these answered satisfactorily.
2. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason, without my legal rights being affected.
3. I agree to:
Take part in the interview
Allow the interview to be audio-recorded
Complete a short questionnaire on my role, level of experience and training received
Allow the information I supply to be used anonymously
in reports, publications, presentations or other appropriate
dissemination methods
4. I would like a summary of the results of the study when it is completed.
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Name of participant Date Signature
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Name of researcher Date Signature
Study name – date – version number