CONSENT SHEET

TITLE: A triangulation study to assess the behavior of

patients, family members and health care providers

regarding DOTS program in selected DOTS centres of Delhi.

You are being requested to be a part of the above mentioned study purely on voluntary basis.
Before agreeing to participate in the present study, it is important that you read and
understand the following information. An oral presentation of this document shall be made, if
you have any questions, please discuss during the presentation. You will be provided with
two copies of this form, please sign the original copy and submit to us for our records and
please retain the duplicate copy for your reference and records.

PURPOSE: To assess the behavior of patients, family members and health care providers regarding
dots program in selected DOTS centres of Delhi.

RISK: There is no risk associated with this study for the participants of the study.

COMPENSATION: You will not be entitled for any compensation for participation in this
study. Your participation in this study is completely voluntary. Regarding any doubts/
questions about this study, you may contact the investigator personally.

CONFIDENTIALITY: Your name and other details will be kept confidential. It will be
accessible to the study personnel and, if necessary, to the Jamia Hamdard Institution Review
Board.

RIGHT TO WITHDRAW: By your own free will, at any time, you can withdraw from
participation in the study and by doing so; it will not have any negative effect in your
academics.

VOLUNTEER’S DECLARATION: I have thoroughly read and understood the above

information and I am ready to participate in this study on voluntary basis.

Volunteer’s name: Ms./Mr._________________________

Volunteer’s signature: ____________________________

Investigator’s name: Ms. Preeti Rohilla

Contact number: 9958866809
Email id: preetirohilla94@gmail.com