FREE PRIOR INFORMED CONSENT FORM

Date: _____

I, ________________________ , state that I am over 18 years of age and that I

voluntarily agree to participate in a research project conducted by _________________
entitled _______________________. The research is being conducted in order to
_____________________. The specific task I will perform will require time for me to
participate and answer the questions the researcher will give.

I acknowledge that ________________________ has explained the task to me

fully; has informed me that I may withdraw from participation at any time without
prejudice or penalty; has offered to answer any questions that I might have concerning
the research procedure; has assured me that any information that I give will be used for
research purposes only and will be kept confidential.

___________________________ ___________________________
[Signature of the researcher] [Signature of participant//s]

___________________________ ___________________________
[Signature of the Thesis adviser] [Signature of informed witness/es]