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II. IRB SAMPLE CONSENT FORM

We are seeking your participation in a research project involving a study of the burden borne by persons providing home care to victims of an immobilizing stroke. It is our understanding that you have provided the primary home care to a stroke victim, either a spouse, a parent, or a parent-in-law, for at least one year. This study will involve about forty persons who, like yourself, provide such care.

If you agree to participate, you will be interviewed about the care you provide to the stroke victim and about your feelings toward him or her. The interview will last about one hour. Your participation will not subject you to any physical risk or pain, but, because some of the interview questions are very personal, you may be subject to some stress or embarrassment. Your name will not be recorded on the interview sheets: an anonymous code will be used, and your replies will be known to at most two persons, the interviewer and Dr. _________, the director of this study. You may be assured that any reports of this research will contain only data of an anonymous or statistical nature: your name, or the name of the stroke victim, will not be used.

The goal of this research is to determine what burdens, physical and psychological, are borne by those who provide home care of immobilized stroke victims. It is hoped that stroke support groups and the medical community will be able to use our research to ease the burdens of persons such as yourself. We cannot promise that your participation in this study will be of any direct benefit to you. You may find some therapeutic value in discussing the problems you encounter in caring for the stroke victim. You will receive no monetary compensation for participating in this study.

We are planning a follow-up study to take place about one year from now, and you may be asked, at that time, to agree to another interview. However, giving your permission to participate in the present study in no way obligates you to participate in the follow-up study.

Any questions you have regarding this research may be directed to the interviewer or to Dr. __________ at ____________. Information involving the conduct and review of research involving humans can be obtained from the following member of the Trinity University Institutional Review Board: _______________ at 999-_____.

Your signature below indicates that you agree to participate in this research and further indicates that:

1.   You have read and understand the information written above;

2.   You understand that participation is voluntary and that refusal to participate will not penalize you in any way; and

3.   You understand that you are free to withdraw from participation at any time without penalty.

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Participant                                       Date

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Interviewer                                      Date