340 FR 1 (2013-1) This template language should be inserted into the consent form or compound authorization form for those studies that will enroll subjects who may become decisionally impaired during the course of their participation in the study to allow the subject to name an individual that he/she would like to act as his/her surrogate to provide permission for the subject’s continuation in the study. Advance Research Directive If at any time during this study my ability to give informed consent becomes impaired, then I would like _____________________________ to make decisions on my behalf regarding my continued participation in this study. In the event that he/she is unable or unwilling to perform this function, then I would like ______________________________ to make decisions on my behalf regarding my continued participation in this study.