1. I have freely volunteered to participate in this experiment.
2. I am willing to be observed during the experiment.
3. I have been informed in advance what my task(s) will be and what procedures will be followed.
4. I have been given the opportunity to ask questions and have had my questions answered to my satisfaction.
5. I am aware that I have the right to withdraw consent and to discontinue participation at any time, without prejudice to my future treatment.
6. My signature below may be taken as affirmation of all the above statements; it was given prior to my participation in this study.

____________            _______________            ___________ 

Name                           Signature                            Date