Evaluation

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