Neurological Research Study Participation Agreement

Study Information

Study Title: [Insert Study Title] Principal Investigator: [Insert Name], MD Institution: [Insert Institution Name] Study ID: [Insert Protocol Number]

Participant Information

Name: ________________________ Date of Birth: _________________ Medical Record #: _____________

Agreement Terms

1. Voluntary Participation

I understand that my participation in this neurological research study is entirely voluntary. I may withdraw at any time without affecting my medical care.

2. Study Procedures

I agree to participate in the following procedures:

• Clinical examinations
• Neurological assessments
• [List specific procedures]
• Follow-up visits as scheduled

3. Risks and Benefits

• Potential Risks: [Detail specific risks]
• Expected Benefits: [Detail potential benefits]

4. Confidentiality

I understand that:

• My personal information will be kept confidential
• Data will be coded and stored securely
• Results may be published without identifying me

5. Financial Considerations

• Compensation: [Detail compensation if applicable]
• Costs covered: [List covered expenses]
• Additional costs: [List any participant responsibilities]

Signatures

Participant Signature: _________________ Date: _________

Investigator Signature: ________________ Date: _________

Witness Signature: ____________________ Date: _________

Contact Information

Principal Investigator: [Phone] Research Coordinator: [Phone] Emergency Contact: [Phone]