Patient Consent to Participate in a Research Study-Example


An example of a scripted patient consent form that was designed to be read to and interpreted for patients with limited English language skills. The example describes the pilot study to the prospective participant, including who will be involved, why it is being done, how the study will proceed, what is expected from participants, and how protected health information will be handled.


Program managers, researchers, legal departments, and other program stakeholders.

Helpful Tips

This example was designed for a pilot study of medication therapy management services that were delivered by a pharmacist via videoconferencing and facilitated by a community health worker. Prospective study participants had limited English language skills. The example could be modified for other purposes.

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