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<title>General Information About This Study and the Researchers</title>
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<p class=MsoNormal align=center style='text-align:center;tab-stops:1.0in'><i
style='mso-bidi-font-style:normal'><span style='font-size:16.0pt;color:blue'><o:p> </o:p></span></i></p>
<p class=MsoNormal><b style='mso-bidi-font-weight:normal'>Study Title:<span
style='mso-spacerun:yes'> </span></b>test test test, a
randomized controlled trial</p>
<p class=MsoNormal><i style='mso-bidi-font-style:normal'><o:p> </o:p></i></p>
<p class=MsoNormal><b style='mso-bidi-font-weight:normal'>More test stuff<o:p></o:p></b></p>
<p class=MsoNormal><b style='mso-bidi-font-weight:normal'><o:p> </o:p></b></p>
<p class=MsoNormal style='tab-stops:right 5.5in'><b style='mso-bidi-font-weight:
normal'>Name of Principal Investigator on this Study:<span
style='mso-spacerun:yes'> </span></b>NAME </p>
<p class=MsoNormal style='tab-stops:right 5.5in'><o:p> </o:p></p>
<p class=MsoNormal style='margin-bottom:6.0pt'><b style='mso-bidi-font-weight:
normal'>MORE test stuff: <span style='mso-spacerun:yes'> </span><a
name=facilityname><span style='mso-spacerun:yes'> </span></a><span
style='mso-spacerun:yes'> </span><o:p></o:p></b></p>
<p class=MsoNormal style='margin-bottom:12.0pt'>Please sign and date to show
that you have read all of the above guidelines.<span style='mso-spacerun:yes'>
</span>Please do not sign unless you have read this entire consent form.<span
style='mso-spacerun:yes'> </span>If you do not want to sign, you don’t have
to, but if you don’t you cannot participate in this research study. </p>
<p class=MsoNormal style='margin-top:0in;margin-right:-40.3pt;margin-bottom:
12.0pt;margin-left:0in;tab-stops:112.5pt 5.5in'><b style='mso-bidi-font-weight:
normal'><u><span style='font-size:14.0pt'>Signature for study participation<o:p></o:p></span></u></b></p>
<p class=MsoNormal style='margin-right:-40.5pt;line-height:13.0pt;mso-line-height-rule:
exactly;tab-stops:112.5pt 5.5in'><a name=surveydate>______________</a><span
style='mso-spacerun:yes'> </span><span style='mso-tab-count:1'> </span><a
name=Q027A000>___________________________________________________</a><span
style='mso-spacerun:yes'> </span></p>
<p class=MsoNormal style='margin-right:-49.5pt;line-height:13.0pt;mso-line-height-rule:
exactly;tab-stops:112.5pt 5.5in 5.75in'>(Date / Time)<span style='mso-tab-count:
1'> </span>(Printed Name of Participant) – Respondent #<a
name=respondent><span style='mso-tab-count:1'> </span></a></p>
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