Health Literacy Consent Form

Title	Identifying and Responding to the Health Literacy Needs of People Living with MND/ALS – A Coordinated National Approach
Short Title	Finding Clear and Useful Health Information about MND/ALS
Protocol Number	Version 3, 26 May 2021
Principal Investigator	Dr Susan Mathers
Location	Calvary Health Care Bethlehem, 152 Como Parade West, Parkdale 3195

Declaration by Participant

I have read the Participant Information Sheet or someone has read it to me in a language that I understand.
I understand the purposes, procedures and risks of the research described in the project.
I understand my identity will not be disclosed to anyone else or in publications or presentations.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.
I freely agree to participate in this research project as described and understand that I am free to withdraw at any time during the study without affecting my future health care.
I understand that I will be given a copy of this document to keep.

Participant Details

Salutation *

Salutation Other

Family Name *

First Given Name *

Other Given Name(s)

Date of Birth *

Please type the date in dd-mm-yyyy format. (e.g. 19-02-2021)

Email Address *

Mobile Number

Declaration

Signature

Please use your mouse to draw your signature in the below box.

Signer Name *

Leave this field blank

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. The code you enter is case sensitive. You must type the code exactly as it is seen in the image below.

What code is in the image? *

Enter the characters shown in the image.