Research Participation Consent Form for Geriatric Studies

Study Information

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

Participant Information

Name: ________________________ Date of Birth: ________________ Medical Record Number: ________

Consent Declaration

I, the undersigned, confirm that:

• I have read and understood the study information sheet dated [Date]
• I have had the opportunity to ask questions and discuss this study
• I understand that my participation is voluntary
• I agree to my medical records being reviewed for this research
• I understand that I can withdraw at any time without affecting my medical care

Special Considerations for Geriatric Participants

Cognitive Assessment

• Mini-Mental State Examination (MMSE) Score: ___/30
• Date of Assessment: ________________
• Assessor's Name: __________________

Capacity Determination

□ Participant has capacity to consent independently □ Legal representative/proxy consent required

Emergency Contact Information

Primary Contact: Name: ________________________ Relationship: __________________ Phone: ________________________

Signatures

Participant Signature: _______________ Date: _______________

Witness Signature: _________________ Date: _______________

Investigator Signature: _____________ Date: _______________

Legal Representative (if applicable)

Name: ________________________ Relationship to Participant: ________ Signature: _____________________ Date: _______________