ࡱ> Y  bjbj 8.iiM | | ###8[4<#Z(   ===dffffff$?=====  4=F  d=dV#@d$ Ѐmq# P0#xAFd$d$x$y=======X================| Y : UNIVERSITY OF WASHINGTON CONSENTIMIENTO PARA PARTICIPAR DE MANERA VOLUNTARIA COMO SUJETO DEUNAINVESTIGACIN - FORMULARIO ABREVIADO Ttulo del estudio: _____________________________________________________________ ____________________________________________________________________________ Nombre del investigador principal, departamento y nmero de telfono: ____________________________________________________________________________ Se le pide que participe en una investigacin. Dado que no hay informacin por escrito sobre la investigacin en su idioma, la informacin se le brindar de manera verbal. Con la ayuda de un intrprete, los investigadores le darn la misma informacin que otros participantes recibiran en ingls, comenzando con informacin importante con respecto a su decisin de si va a participar o no. Puede hacer preguntas y luego puede decidir si va a participar en la investigacin. Si acepta participar, recibir una copia firmada de este documento y una copia de la informacin por escrito en ingls. Puede comunicarse con ___________________________________ al nmero de telfono ( ) ________________ en cualquier momento que tenga preguntas sobre la investigacin o si cree que ha sufrido una lesin por participar en este estudio. Puede comunicarse con el Comit de Revisin Institucional (Institutional Review Board, IRB) de UW al nmero206-543-0098 o mediante el correo electrnico  HYPERLINK "mailto:hsdinfo@uw.edu" hsdinfo@uw.edu si tiene preguntas sobre sus derechos como sujeto de una investigacin. Firme a continuacin si: Se le ha descrito el estudio de investigacin en un idioma que entiende. Ha podido hacer las preguntas que tena sobre el estudio. Acepta participar de manera voluntaria. NOMBRE DEL SUJETO FIRMA DEL SUJETO FECHA La presentacin verbal de la informacin del consentimiento mediante un intrprete requiere un testigo imparcial. El intrprete puede actuar como testigo. Firme a continuacin si ha sido testigo del consentimiento. NOMBRE DEL TESTIGO FIRMA DEL TESTIGO FECHA Si la capacidad de un sujeto para dar su consentimiento se ve reducida, solo podr participar en la investigacin si un representante legalmente autorizado (legally authorized representative, LAR) da el consentimiento en su nombre. NOMBRE DEL REPRESENTANTE FIRMA DEL REPRESENTANTE FECHA RELACIN CON EL SUJETO     Document Date & VersionResearcher Date & VersionSpanish 06.01.2023[Insert consent form title]mm/dd/yyyyVersion 1.0Version x.xPage  PAGE 1 of  NUMPAGES 2 [\_` " % & ' l m n  h  B 묗qaqqaqRRRhMvhOJQJmH XsH XhB*OJQJmH XphsH X%hMvhMvB*OJQJmH XphsH X%hMvhB*OJQJmH XphsH X)hMvh;MB*OJQJ^JmH XphsH X/hMvh;M5B*OJQJ\^JmH XphsH X"h,x5B*OJQJmH XphsH X(hMvhMv5B*OJQJmH XphsH X(hMvh5B*OJQJmH XphsH X & ' m n   J   5~ $ & Fa$gd,x$a$gd,x $7$8$H$a$gd,x 7$8$H$gd#9 7$8$H$gds0 $7$8$H$a$gd;MB     I J     > X 45}~ٯygyRR)hMvhB*OJQJ^JmH XphsH X#jhMvhUmH XsH X hMvh0JOJQJmH XsH XjhMvhUmH XsH X+hMvh6B*OJQJ]mH XphsH X)hMvh#9B*OJQJ^JmH XphsH X)hMvh;MB*OJQJ^JmH XphsH X%hMvhMvB*OJQJmH XphsH X%hMvhB*OJQJmH XphsH X ~   ͺ{{{{fͥQ{{{{f)hMvh[5B*OJQJ^JmH XphsH X)hMvhMvB*CJOJQJmH XphsH X)hMvhB*CJOJQJmH XphsH X)hMvh;MB*OJQJ^JmH XphsH X)hMvh#9B*OJQJ^JmH XphsH X%hMvhMvB*OJQJmH XphsH X%hMvhB*OJQJmH XphsH X hMvhOJQJ^JmH XsH XhMvhOJQJmH XsH X  3$  $d7$8$H$Ngd,x$  7$8$H$gd,x$$  7$8$H$a$gd,x$  7$8$H$a$gd,x  7$8$H$gd;M  $d7$8$H$Ngd;M 7$8$H$gd;M2345KLMNOPQRSTUVWXӽӪkVkNJJNJJNJJNJh"jh"U)hh[5B*OJQJ^JmH XphsH X)hMvhMvB*CJOJQJmH XphsH X)hMvhB*CJOJQJmH XphsH X)hMvh[5B*OJQJ^JmH XphsH X%hMvhMvB*OJQJmH XphsH X+hMvh6B*OJQJ]mH XphsH X%hMvhB*OJQJmH XphsH X1hMvh[5B*CJOJQJ^JaJmH XphsH X345LMOPRSUVXYZrs $$Ifa$gdR/ $IfgdR/gdR/  $d7$8$H$Ngd;M  7$8$H$gd[5  $d7$8$H$Ngd[5XYZqrs併併iiOiOi3jhR/0JCJOJPJQJU^JaJnHtH*hR/0JCJOJPJQJ^JaJnHtH3hR/0JB*CJOJPJQJ^JaJnHphtHhR/0JPJ&hWCJOJPJQJ^JaJnHtHhR/CJaJ hR/PJhR/0J6PJ.hR/CJOJPJQJ^JaJmH nHsH tH&hR/CJOJPJQJ^JaJnHtHhR/h"mddXL $$Ifa$gdR/ $$Ifa$gdR/ $IfgdR/kd$$IflF&FF  t00*    44 lBBa0ytR/pg[O $$Ifa$gdR/ $$Ifa$gdR/ $IfgdR/kd$$IflF&FFF  t00*    44 lBa0ytR/mddX $$Ifa$gdR/ $IfgdR/kd$$IflF&FF t00*    44 lBBa0ytR/     廳1hMvh[5B*CJOJQJ^JaJmH XphsH Xh"h,=hR/hR/CJaJ&hR/CJOJPJQJ^JaJnHtH*hR/0JCJOJPJQJ^JaJnHtH3jhR/0JCJOJPJQJU^JaJnHtH     pnnllU  $d7$8$H$Ngd;Mkdd$$IflF&F t00*    44 lBa0ytR/6&P1h:p"/ =!"#$% DyK yK ,mailto:hsdinfo@uw.edu $$If0!vh#v#v#v :V l t00*,555 / / / / / / /  BBa0ytR/$$If0!vh#v#v#v :V l t00*,555 / / / / / / / Ba0ytR/$$If0!vh#v#v#v :V l t00*,555 / BBa0ytR/$$If0!vh#v#v#v :V l t00*,555 / Ba0ytR/x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmHsHtH DA`D Default Paragraph FontNi@N  Table Normal4 l4a (k (No List b/b ;MDefault 7$8$H$-B*CJOJQJ^J_HaJmHphsHtH HH ;M Balloon TextCJOJQJ^JaJ44 ;MHeader  !4 @"4 ;MFooter  !6U`16 # Hyperlink >*B*phB' AB 0MComment ReferenceCJaJ<R< 0M Comment TextCJaJ:a: 0MComment Text Char@jQR@ 0MComment Subject5\F/F 0MComment Subject Char5\D D Y0RevisionCJ_HaJmHsHtH >/> R/ Footer CharCJaJmHsH.)@. 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