ࡱ> 352 Xbjbj 4 M***8b~*  ! ! ! ! ! ! $J"$E E 4Z JJJF J JJt[|*R p 0 %|%%JE E ` % :  Regained Capacity Consent Form Title of Study: Principal Investigator: Dr. Phone Number: Co-Investigators: Because your illness made it impossible for you to participate fully in the informed consent process, consent to participate in this research study was obtained from your substitute decision maker (family member). Your substitute decision maker believed you would have wished to participate in this research if you had been able to express your own opinion at the beginning of the research study. Informed consent is essential throughout a research study. This means in your situation, you are now being given the opportunity to agree or disagree with the decision made by your substitute decision maker for you to participate. A member of the study team will go over the Information and Consent Form signed on your behalf, and answer all of your questions about the study. If you agree to stay in the study, please sign below. If you do not agree, tell the study staff so that all data already collected about you will be destroyed. If you have questions or concerns about your rights as a study participant, you may contact the Research Ethics Office, at 780-492-2615. This office is independent of the researchers. Consent: I wish to remain in the study. I have reviewed the information and consent form originally signed on my behalf, and my questions have been answered. ______________________________________ ______________________________________ Participants Name Signature and Date ______________________________________ ______________________________________ Investigator/Delegates Name Signature and Date A signed copy of this consent form will be given to the participant, as well as the original consent form signed on behalf of the participant.     Insert letterhead Version: 26 Oct 2016 Page  PAGE 1 of 1 !"+01234KLPSactuvw " K R k    9 >  M Q c m ߾tlth$@CJaJhG{h2CJaJhG{CJaJhG{hh'CJaJhG{h9CJaJhG{heCJaJhG{hCJaJhG{hD CJaJhe hG{he hG{h. hG{hqhG{he5hG{hq5 h2+#hD hG{hD aJh2+#hD CJ)!"34bcvw  $ % dgd-%Cdgd-%Cgd gd-%Cgd2+# &d P gdqgdegdq $dNgdq$a$gdD gdD m } # $ % wyz    ·¯ݣ~zsososh`\`\`\`h1jh1U hh'h<hp hh'hD h9 hh'h.h-%Ch.hG{h5qCJaJhG{h2CJaJh-%Ch-%C>*CJaJhQOCJaJh h-%CCJaJh-%Ch-%CCJaJhCCJaJh$GCJaJh-%CCJaJhG{hD CJaJh$@CJaJh CJaJ$ Hxyz{   ()U$a$gd?ggdD Hgd. Hgd9()3>EFLMNOTVWX hh'h<h 0JmHnHu hG{0JjhG{0JUh-%ChG{h>'lh?gh1UVWXgdD 21h:p?g/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 D Normal_HmH sH tH J@J D Heading 1$p@&^p`5>*DA`D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 6>@6 D Title$a$ 5>*CJ2B@2 D Body TextCJRRR D Body Text Indent 2dx^4@"4 D Header  !4 @24 D Footer  !.)@A. D Page NumberH@RH `O Balloon TextCJOJQJ^JaJB'`aB ukComment ReferenceCJaJ4@r4 uk Comment TextFoF ukComment Text Char mH sH tH @j@qr@ ukComment Subject5\RoR ukComment Subject Char5\mH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] X& LLLOm X  UX ;BDO!@ @H 0(  0(  B S  ?   VYQW   VY3+022Labbtuvw "=JKRktt9>%z      >?EOTVY+0224Labbtuvw "=JKRktt9>%z      >?EOTVYGSf))^)`CJ$OJQJo(q ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(GSA@1G{ c)_D l 2$@h' )q' V!Pg"2+#Z%5*+k36Kd8ZD>/?-%Q`?u>'A/