Maikling Form ng Pahintulot na Lumahok sa isang Pananaliksik na ...
Maikling Form ng Pahintulot na Lumahok sa isang Pananaliksik na ...
Maikling Form ng Pahintulot na Lumahok sa isang Pananaliksik na ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<stro<strong>ng</strong>>Maikli<strong>ng</strong></stro<strong>ng</strong>> <stro<strong>ng</strong>>Form</stro<strong>ng</strong>> <strong>ng</strong> <strong>Pahintulot</strong> <strong>na</strong> <strong>Lumahok</strong> <strong>sa</strong> i<strong>sa</strong><strong>ng</strong> Pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> Pag-aaralDa<strong>na</strong>-Farber/ Harvard Cancer Center (DF/HCC)BIDMC/BWH/BCH/DFCI/MGH/Mga Affiliate <strong>sa</strong> NetworkNumero <strong>ng</strong> Protocol: ___________________________Pa<strong>ng</strong>alan <strong>ng</strong> Pa<strong>ng</strong>u<strong>na</strong>hi<strong>ng</strong> Tagasiya<strong>sa</strong>t: ____________________________________________Pa<strong>ng</strong>alan <strong>ng</strong> Nagpapahintulot <strong>na</strong> Tagasiya<strong>sa</strong>t: _______________________________________A<strong>ng</strong> paggamit <strong>ng</strong> “ikaw” <strong>sa</strong> kabuuan <strong>ng</strong> dokumento<strong>ng</strong> ito ay tumutukoy <strong>sa</strong> kalahok <strong>sa</strong> pa<strong>na</strong><strong>na</strong>liksik.Tumutukoy rin ito <strong>sa</strong> tao<strong>ng</strong> awtori<strong>sa</strong>do<strong>ng</strong> magbigay <strong>ng</strong> pahintulot para <strong>sa</strong> pakikilahok <strong>ng</strong> subject <strong>sa</strong>pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> pag-aaral <strong>na</strong> ito.<strong>Pahintulot</strong> <strong>na</strong> <strong>Lumahok</strong> <strong>sa</strong> i<strong>sa</strong><strong>ng</strong> Pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> Pag-aaralHinihili<strong>ng</strong> <strong>sa</strong> iyo<strong>ng</strong> lumahok <strong>sa</strong> i<strong>sa</strong><strong>ng</strong> pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> pag-aaral. Ma<strong>ng</strong>yari<strong>ng</strong> huwag madaliin a<strong>ng</strong>iyo<strong>ng</strong> pagpapasya at talakayin ito ka<strong>sa</strong>ma <strong>ng</strong> iyo<strong>ng</strong> pamilya at mga kaibigan.Bago ka suma<strong>ng</strong>-ayon <strong>na</strong> makilahok, dapat <strong>sa</strong>bihin <strong>sa</strong> iyo <strong>ng</strong> tagasiya<strong>sa</strong>t a<strong>ng</strong>:1) Mga layunin, hakba<strong>ng</strong>, at tagal <strong>ng</strong> pa<strong>na</strong><strong>na</strong>liksik;2) Anuma<strong>ng</strong> mga hakba<strong>ng</strong> <strong>na</strong> pa<strong>ng</strong>-eksperimento;3) Anuma<strong>ng</strong> mga peligro, pagkabali<strong>sa</strong>, at paki<strong>na</strong>ba<strong>ng</strong> <strong>sa</strong> pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> makatuwira<strong>ng</strong>maa<strong>sa</strong>han;4) Anuma<strong>ng</strong> potensyal <strong>na</strong> mapapaki<strong>na</strong>ba<strong>ng</strong>a<strong>ng</strong> alter<strong>na</strong>tibo<strong>ng</strong> mga hakba<strong>ng</strong> o pa<strong>ng</strong>gagamot; at,5) Paano papa<strong>na</strong>tilihin a<strong>ng</strong> pagigi<strong>ng</strong> kumpedensyal at paano poprotektahan a<strong>ng</strong> impormasyon <strong>sa</strong>iyo<strong>ng</strong> kalusugan.Ku<strong>ng</strong> <strong>sa</strong>an <strong>na</strong>aa<strong>ng</strong>kop, dapat ri<strong>ng</strong> <strong>sa</strong>bihin <strong>sa</strong> iyo <strong>ng</strong> tagasiya<strong>sa</strong>t a<strong>ng</strong>:1) Anuma<strong>ng</strong> <strong>na</strong>aa<strong>ng</strong>kop <strong>na</strong> kabayaran o medikal <strong>na</strong> pa<strong>ng</strong>gagamot ku<strong>ng</strong> may maga<strong>na</strong>p <strong>na</strong> pin<strong>sa</strong>la<strong>sa</strong> katawan;2) Posibilidad <strong>ng</strong> mga hindi i<strong>na</strong>a<strong>sa</strong>ha<strong>ng</strong> peligro;3) Mga sitwasyon ku<strong>ng</strong> <strong>sa</strong>an maaari<strong>ng</strong> ihinto <strong>ng</strong> tagasiya<strong>sa</strong>t a<strong>ng</strong> iyo<strong>ng</strong> pakikilahok;4) Anuma<strong>ng</strong> mga dagdag <strong>na</strong> gastos <strong>sa</strong> iyo;5) Magigi<strong>ng</strong> resulta ku<strong>ng</strong> magpasya ka<strong>ng</strong> ihinto a<strong>ng</strong> pakikilahok;6) Kailan ka <strong>sa</strong><strong>sa</strong>bihan tu<strong>ng</strong>kol <strong>sa</strong> mga bago<strong>ng</strong> kaalaman <strong>na</strong> maaari<strong>ng</strong> makaapekto <strong>sa</strong> iyo<strong>ng</strong>kagustuha<strong>ng</strong> lumahok;7) Ila<strong>ng</strong> tao a<strong>ng</strong> makikilahok <strong>sa</strong> pag-aaral; at,8) Para <strong>sa</strong> mga pagsubok <strong>sa</strong> klinika: Magigi<strong>ng</strong> available a<strong>ng</strong> i<strong>sa</strong><strong>ng</strong> paglalarawan <strong>ng</strong> pagsubok <strong>sa</strong>klinika <strong>na</strong> ito <strong>sa</strong> www.ClinicalTrials.gov, tulad <strong>ng</strong> iniaatas <strong>ng</strong> Batas <strong>ng</strong> U.S. Hindi mag<strong>sa</strong><strong>sa</strong>maa<strong>ng</strong> Web site <strong>ng</strong> impormasyon <strong>na</strong> makakapagpakilala <strong>sa</strong> iyo. I<strong>sa</strong><strong>ng</strong> buod la<strong>ng</strong> <strong>ng</strong> mga resultaa<strong>ng</strong> maaari<strong>ng</strong> i<strong>sa</strong>ma <strong>sa</strong> Web site. Maaari ka<strong>ng</strong> magha<strong>na</strong>p <strong>sa</strong> Web site <strong>sa</strong> anuma<strong>ng</strong> oras.Ku<strong>ng</strong> <strong>sa</strong><strong>sa</strong><strong>ng</strong>-ayon ka<strong>ng</strong> makilahok, bibigyan ka <strong>ng</strong> may lagda<strong>ng</strong> kopya <strong>ng</strong> dokumento<strong>ng</strong> ito ati<strong>sa</strong><strong>ng</strong> kopya <strong>ng</strong> form <strong>ng</strong> pahintulot <strong>sa</strong> wika<strong>ng</strong> I<strong>ng</strong>les para <strong>sa</strong> pag-aaral.Maaari ka<strong>ng</strong> makipag-ug<strong>na</strong>yan <strong>sa</strong>/kay<strong>sa</strong>anuma<strong>ng</strong> oras <strong>na</strong> mayroon ka<strong>ng</strong> mga tano<strong>ng</strong> tu<strong>ng</strong>kol <strong>sa</strong> pag-aaral o pin<strong>sa</strong>la <strong>sa</strong> katawa<strong>ng</strong> <strong>na</strong>uug<strong>na</strong>y<strong>sa</strong> pa<strong>na</strong><strong>na</strong>liksik.Pahi<strong>na</strong> 1 <strong>ng</strong> 2
<stro<strong>ng</strong>>Maikli<strong>ng</strong></stro<strong>ng</strong>> <stro<strong>ng</strong>>Form</stro<strong>ng</strong>> <strong>ng</strong> <strong>Pahintulot</strong> <strong>na</strong> <strong>Lumahok</strong> <strong>sa</strong> i<strong>sa</strong><strong>ng</strong> Pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> Pag-aaralDa<strong>na</strong>-Farber/ Harvard Cancer Center (DF/HCC)BIDMCBIDMCIBWH/BCHIDFCIIMGHIMga Affiliate <strong>sa</strong> NetworkMaaari ka ri<strong>ng</strong> makipag-ug<strong>na</strong>yan <strong>sa</strong> Institutio<strong>na</strong>l Review Board <strong>ng</strong> Da<strong>na</strong>-Farber Cancer Institute <strong>sa</strong>numero <strong>ng</strong> telepono<strong>ng</strong> (617) 632-3029 ku<strong>ng</strong> mayroon ka<strong>ng</strong> mga tano<strong>ng</strong> tu<strong>ng</strong>kol <strong>sa</strong> iyo<strong>ng</strong> mgakarapatan bila<strong>ng</strong> i<strong>sa</strong><strong>ng</strong> subject <strong>sa</strong> pa<strong>na</strong><strong>na</strong>liksik.A<strong>ng</strong> pakikilahok mo <strong>sa</strong> pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> ito ay ku<strong>sa</strong><strong>ng</strong>-loob, at hindi ka paparu<strong>sa</strong>han o mawawalan<strong>ng</strong> anuma<strong>ng</strong> mga paki<strong>na</strong>ba<strong>ng</strong> ku<strong>ng</strong> ikaw ay tuma<strong>ng</strong>gi<strong>ng</strong> makilahok o magpasya<strong>ng</strong> huminto.A<strong>ng</strong> paglagda <strong>sa</strong> dokumento<strong>ng</strong> ito ay <strong>na</strong><strong>ng</strong>a<strong>ng</strong>ahuluga<strong>ng</strong> pa<strong>sa</strong>lita<strong>ng</strong> inilarawan <strong>sa</strong> iyo a<strong>ng</strong>pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> pag-aaral, kabila<strong>ng</strong> <strong>na</strong> a<strong>ng</strong> impormasyon <strong>sa</strong> itaas, at ku<strong>sa</strong><strong>ng</strong>-loob ka<strong>ng</strong>suma<strong>ng</strong>-ayon <strong>na</strong> makilahok.Lagda <strong>ng</strong> KalahokO Ki<strong>na</strong>tawan <strong>na</strong> Pi<strong>na</strong>pahintulutan <strong>ng</strong> BatasPet<strong>sa</strong>Kaug<strong>na</strong>yan <strong>ng</strong> Ki<strong>na</strong>tawan <strong>na</strong> Pi<strong>na</strong>pahintulutan <strong>ng</strong> Batas <strong>sa</strong> KalahokLagda <strong>ng</strong> Interpreter/SaksiPet<strong>sa</strong>Pahi<strong>na</strong> 2 <strong>ng</strong> 2
Addendum <strong>sa</strong> <stro<strong>ng</strong>>Maikli<strong>ng</strong></stro<strong>ng</strong>> <stro<strong>ng</strong>>Form</stro<strong>ng</strong>> <strong>ng</strong> <strong>Pahintulot</strong> <strong>na</strong> <strong>Lumahok</strong> <strong>sa</strong> i<strong>sa</strong><strong>ng</strong> Pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> Pag-aaralDa<strong>na</strong>.-Farber/ Harvard Cancer Center (DF/HCC)BIDMCBIDMCIBWH/BCHIDFCIIMGHIMga Affiliate <strong>sa</strong> NetworkNumero <strong>ng</strong> Protocol: ______________________________Pa<strong>ng</strong>alan <strong>ng</strong> Pa<strong>ng</strong>u<strong>na</strong>hi<strong>ng</strong> Tagasiya<strong>sa</strong>t: _________________________________________Pa<strong>ng</strong>alan <strong>ng</strong> Nagpapahintulot <strong>na</strong> Tagasiya<strong>sa</strong>t: ____________________________________A<strong>ng</strong> paggamit <strong>ng</strong> “ikaw” <strong>sa</strong> kabuuan <strong>ng</strong> dokumento<strong>ng</strong> ito ay tumutukoy <strong>sa</strong> kalahok <strong>sa</strong> pa<strong>na</strong><strong>na</strong>liksik.Tumutukoy rin ito <strong>sa</strong> tao<strong>ng</strong> awtori<strong>sa</strong>do<strong>ng</strong> magbigay <strong>ng</strong> pahintulot para <strong>sa</strong> pakikilahok <strong>ng</strong> subject <strong>sa</strong>pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> pag-aaral <strong>na</strong> ito.Addendum para <strong>sa</strong> Mga Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaralHinihili<strong>ng</strong> <strong>sa</strong> iyo<strong>ng</strong> lumahok <strong>sa</strong> ila<strong>ng</strong> opsyo<strong>na</strong>l <strong>na</strong> pag-aaral. Ku<strong>ng</strong> magpasya ka<strong>ng</strong> huwagmakilahok <strong>sa</strong> alinman <strong>sa</strong> mga opsyo<strong>na</strong>l <strong>na</strong> pag-aaral, maaari ka pa ri<strong>ng</strong> makilahok <strong>sa</strong> pa<strong>ng</strong>u<strong>na</strong>hi<strong>ng</strong>pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> pag-aaral. Ma<strong>ng</strong>yari<strong>ng</strong> huwag madaliin a<strong>ng</strong> iyo<strong>ng</strong> pagpapasya at talakayin itoka<strong>sa</strong>ma <strong>ng</strong> iyo<strong>ng</strong> pamilya at mga kaibigan.A<strong>ng</strong> pakikilahok mo <strong>sa</strong> opsyo<strong>na</strong>l <strong>na</strong> pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> ito ay ku<strong>sa</strong><strong>ng</strong>-loob, at hindi ka paparu<strong>sa</strong>han omawawalan <strong>ng</strong> anuma<strong>ng</strong> mga paki<strong>na</strong>ba<strong>ng</strong> ku<strong>ng</strong> ikaw ay tuma<strong>ng</strong>gi<strong>ng</strong> makilahok o magpasya<strong>ng</strong>huminto.Ma<strong>ng</strong>yari<strong>ng</strong> i<strong>sa</strong>ad ku<strong>ng</strong> <strong>na</strong>is mo<strong>ng</strong> makilahok <strong>sa</strong> mga opsyo<strong>na</strong>l <strong>na</strong> pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> pag-aaral ohindi.Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #1: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #2: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #3: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #4: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Pahi<strong>na</strong> 1 <strong>ng</strong> 2
Addendum <strong>sa</strong> <stro<strong>ng</strong>>Maikli<strong>ng</strong></stro<strong>ng</strong>> <stro<strong>ng</strong>>Form</stro<strong>ng</strong>> <strong>ng</strong> <strong>Pahintulot</strong> <strong>na</strong> <strong>Lumahok</strong> <strong>sa</strong> i<strong>sa</strong><strong>ng</strong> Pa<strong>na</strong><strong>na</strong>liksik <strong>na</strong> Pag-aaralDa<strong>na</strong>-Farber/ Harvard Cancer Center (DF/HCC)BIDMCIBWWBCHIDFCI/MGH/Mga Affiliate <strong>sa</strong> NetworkOpsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #5: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #6: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #7: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #8: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #9: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Opsyo<strong>na</strong>l <strong>na</strong> Pag-aaral #10: Hindi <strong>na</strong>aa<strong>ng</strong>kop Oo _________________________ Mga Inisyal Pet<strong>sa</strong> Hindi _________________________ Mga Inisyal Pet<strong>sa</strong>Lagda <strong>ng</strong> KalahokO Ki<strong>na</strong>tawan <strong>na</strong> Pi<strong>na</strong>pahintulutan <strong>ng</strong> BatasPet<strong>sa</strong>Kaug<strong>na</strong>yan <strong>ng</strong> Ki<strong>na</strong>tawan <strong>na</strong> Pi<strong>na</strong>pahintulutan <strong>ng</strong> Batas <strong>sa</strong> KalahokLagda <strong>ng</strong> Interpreter/SaksiPet<strong>sa</strong>Pahi<strong>na</strong> 2 <strong>ng</strong> 2
Change language