NIAPP interview patient consent form, version 002, date: 09/01/2006
Evaluation of the National Infarct
Angioplasty Project Pilots (NIAPP)
Patient ID number:
PATIENT CONSENT FORM FOR FACE-TO-FACE INTERVIEW
Name of Researcher:
Please initial each box
I confirm that I have read and understand the information sheet, dated
[09/01/2006, version 002] for the above study and have had the
opportunity to ask questions.
My participation is voluntary and that I am free to withdraw at any
time, without giving any reason, without my medical care or legal
rights being affected.
I understand that the interview will be audiotaped
I agree to the use of anonymised quotations from the interview in
published materials
I agree that my General Practitioner will be informed of my
participation in this research.
I agree that the interviewer may speak to my carer about their
experiences relating to my care.
I agree to take part in the above study.
________________________ _______________
Name of Patient
Signature
For further information, please contact:
Fiona Sampson
Medical Care Research Unit, University of Sheffield
Telephone: 0114 222 0687
___/___/____
Date
NHS