VERSION 08-07-2013 LANGUAGE IN GREEN IS TO BE CUSTOMIZED AS PER THE STUDY PROTOCOL. THE UNIVERSITY OF CALIFORNIA, IRVINE (UCI) CONSENT CONSENT TO PARTICIPATE AS A HUMAN RESEARCH SUBJECT COVER SHEET [Title of Study] RESEARCH TEAM AT UCI: Lead Researcher at UCI: Name and Title Department Telephone number and e-mail address 24 Hour Telephone number: Other Researchers Finalizing Informed Consent at UCI: Name and Title Department Telephone number and e-mail address STUDY LOCATION(S): UCI STUDY SPONSOR(S): [Name of Sponsor] You are being asked to participate in a research study. Participation is completely voluntary. Please read the information below and ask questions about anything that you do not understand. 1 of 1