INFORMED CONSENT FOR INTERVIEW CASE PRESENTATION I, ____________________________________________________ __________years old, a resident of __________________________________________________________ voluntarily agree to be interviewed for

a case presentation which is being produced by _______________ of _____________. I certify that I have been told of the confidentiality of information collected for this project and the anonymity of my participation; that I have been given satisfactory answers to my inquiries concerning project procedures and other matters; and that I have been advised that I am free to withdraw my consent and to discontinue participation in the project or activity at any time without prejudice. I agree to participate in one or more electronically recorded interviews for this project. I understand that such interviews and related materials will be kept completely anonymous, and that the results of this study may appear in a presentation and be published in a journal. I agree that any information obtained from this research may be used in any way thought best for this study. Signed this _____ day of _________20___ at ________________.

____________________________________ Printed name over signature of interviewee

___________________________

__________________________

WITNESS

ADDRESS

INTERVIEWEERS:

_________________________

ADDRESS

INFORMED CONSENT FOR PHYSICAL ASSESSMENT

CASE PRESENTATION I, ____________________________________________________ __________years old, a resident of __________________________________________________________ fully recognize to be assessed for a case presentation which is being produced by __________________________of _________________________. I certify that I have been told of the confidentiality of information collected for this project and the anonymity of my participation; that I have been given satisfactory answers to my inquiries concerning project procedures and other matters; and that I have been advised that I am free to withdraw my consent and to discontinue participation in the project or activity at any time without prejudice. I hereby submit myself completely voluntary to participate in a physical assessment for this project. I understand that such related materials will be kept completely anonymous, and that the results of this study may appear in a presentation and be published in a journal. I agree that any data obtained from this process may be used in any way thought best for this study. Signed this _____ day of _________20___ at ________________.

____________________________________ Printed name over signature of Participant

___________________________

__________________________

WITNESS

ADDRESS

___________________________

_________________________

INTERPRETER

ADDRESS