Week 9 Informed Consent Letter


Part I: Information Sheet


My name is Ram Pander, a student at South University. I am researching immunization and vaccination. I would like to invite you to participate in this study. Feel free to discuss with anyone you are comfortable with on matters of this research. You may take your time before making the final decision on participating in this study. This consent form may contain words and phrases that you may not understand, feel free to stop me and inquire as we go through the information. If any questions may arise, feel free to ask me.

Purpose of the research

Immunization and vaccination are vital for a healthy life. We want to determine the level of acceptance to different types of vaccinations while identifying the challenges faced by those that were not vaccinated.

Type of Research Intervention

This research will involve your participation in half hour a twenty minutes interview.

Participant Selection

You are being invited to take part in this research because we feel that your experience as a medical practitioner, victim of lack of vaccination, well-immunized adult or parent can contribute much to our understanding and knowledge of immunization and vaccination.

Voluntary Participation

Your participation in this research is entirely voluntary. It is your choice whether to participate or not. If you choose not to participate in all the services you receive at this Centre will continue and nothing will change.


You do not have to answer any question that makes you feel uncomfortable. You do not have to justify not having a response to other questions.


There will be no direct benefit to you, but your participation is likely to help us find out more about how to increase the rate of immunization and help those that have not been immunized in the community.


You will not be provided an incentive to take part in the research.


We will not be sharing information about you to anyone outside of the research team. The information that we collect from this research project will be kept private. Any information about you will have a number on it instead of your name. Only the researchers will know what your number is and we will lock that information up with a lock and key.

Right to Refuse or Withdraw

You do not have to take part in this research if you do not wish to do so. You may stop participating in the interview at any time that you wish. I will give you an opportunity at the end of the interview to review your remarks, and you can ask to modify or remove portions of those, if you do not agree with my notes or if I did not understand you correctly.

Who to Contact

If you have any questions, you can ask them now or later. If you wish to ask questions later, you may contact me.

This proposal has been reviewed and approved by [name of the local IRB], which is a committee whose task it is to make sure that research participants are protected from harm.

Part II: Certificate of Consent

I have read the preceding information, or it has been read to me. I have had the opportunity to ask questions about it, and any questions I have been asked have been answered to my satisfaction. I consent voluntarily to be a participant in this study

Print Name of Participant__________________

Signature of Participant ___________________

Date ___________________________


If illiterate

I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely.

Print name of witness____________ Thumb print of participant

Signature of witness _____________

Date ________________________


Statement by the researcher/person taking consent

I have accurately read out the information sheet to the potential participant, and to the best of my ability made sure that the participant understands what is contained

I confirm that the participant was given an opportunity to ask questions about the study, and all the questions asked by the participant have been answered correctly and to the best of my ability. I confirm that the individual has not been coerced into giving consent, and the consent has been given freely and voluntarily.


 A copy of this ICF has been provided to the participant.

Print Name of Researcher/person taking the consent________________________

Signature of Researcher /person taking the consent__________________________

Date ___________________________


Informed Consent Form for Interviewees

� A literate witness must sign (if possible, this person should be selected by the participant and should have no connection to the research team). Illiterate participants should include their thumbprint as well.

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