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Simple Informed -Form Fill

Section One
Q1

Is the participant illiterate?
Q2

Name of Participant

First Name
Q3

Name of Participant

Last Name
Q4

Date

Date
Q5

Signature of Participant
Q6

Name of Witness

First Name
Q7

Name of Witness

Last Name
Q8

Signature
Q9

Name of Reseracher

First Name
Q10

Name of Reseracher

Last Name