Research Consent Forms
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INTERNATIONAL ISLAMIC UNIVERSITY KULLIYAH OF SCIENCE BIO-MEDICAL SCIENCE CLINICAL AND PHARMACEUTICAL RESEARCH CONCENTRATION S
RESEARCH PARTICIPATION CONSENT FORM Project Title :- “Electromyography study of different rubber tapper tools” Student Investigator :- Mohammed Sarfraz Ahmed Project Supervisor :- Br. Ibrahim Adham bin Taib
Introduction/Purpose: The objective of this study is to assess the comfort and efficiency of the various rubber tapper tools that are being used today employing the use of the Electromyography. You are being requested to participate in this research study: The participant would represent the rubber tapper worker. To perform the same procedure of rubber tapping in a laboratory conditions. The purpose of this study : Is to determine whether the tools used by rubber tappers are contributing to any problems of the hand , wrist , and forearm . To identify which muscles of the forearms are being used during the actual rubber tapping process. To provide information that may aid in the designing of more ergonomically designed tools for carrying out the rubber tapping process. The Number of people involved in this research : 10 Male and 10 Females randomly selected. Procedures :As a participant of this study you will be requested to come to the physiology lab in the biolabs building on the first floor. Your participation in this study would last approximated 20 to 30 minutes and will require just one visit to the lab. 1. Before conducting the experiment you will be asked to fill out a questionnaire that has questions of a non personal nature such as Date _______________
Page 1 of 5
Participants Initials ______
a. b. c. d.
You will be required to fill out your full name. You will be required to indicate whether you are right or a left handed person. You will be asked about your height and weight. You will be required to explain your occupation.
2. You will be asked to perform the rubber tapping process after an explanation from the student investigator. 3. Electrodes that are attached to an electromyography device would be placed on certain muscles of the forearm. 4. Once the electrodes are attached you will perform the rubber tapping process using the rubber tapping tools on two surfaces that would represent the tree. 5. As you are performing the process the readings shall be recorded and documented for later data analysis. At any time in the study, you may decide to withdraw from the study. If you withdraw no more information will be collected from you. When you indicate you wish to withdraw the investigator will ask if the materials already collected in the study can be used. Risks & Discomfort You may get tired while performing the process and get rest at any time. You may feel a little bit awkward when holding the rubber tapping tool , you will be instructed on how to minimize this. The student investigator shall inform you any risks or complications if any associated with your participation in this research.
You have the right to withdraw from the study at any time. Research Related Injuries Immediate necessary medical care is available at the IIUM CLINIC in the event that you are injured as a result of participation in this project. However , there is no commitment by International Islamic University, Student Investigator and his supervisor to provide monetary compensation to you in the event of a project-related injury. For questions about the study or research related injury please contacts the student investigator Sarfraz at 019-974-2770 during regular business hours including weekends and holidays. Benefits There will be no direct benefit to you as a result of participating in this study Your participation in this study may :-
Date _______________
Page 2 of 5
Participants Initials ______
The data gathered as a result of your participation will help identify the risks associated with using the common rubber tapper tools in the Rubber Tapping industry in Malaysia. This data will assist in the future designing of more comfortable and ergonomic tools. This data will help alleviate the risk of injury for approximately 100,000 rubber tappers in Malaysia. Alternatives You have the alternative to choose not to participate in this study. Confidentiality Participation in this study may result in a loss of privacy , since persons other than the investigators might view the data gathered from this experiment. Unless required by law , only the student investigator and his supervisor will have the right to review the data gathered from the experiment. They are required to maintain the confidentiality regarding your identity. Results of this study may be used for teaching , research , publications or presentations at scientific meetings. If your individual results are to be discussed , your identity will be protected by giving a code rather that your name or other identifying information. Financial Information Your participation in this study will involve no costs to you. You will not be paid for your participation in this study. Participation and Withdrawal You can choose whether to be in this study or not. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. You may exercise the option of removing your data from the study. You may also refuse to answer any questions you don’t want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise that warrant doing so. Rights of Research Participations You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims or rights because of your participation in this research study. If you have questions regarding your rights as a research participant, contact Student Investigator: - Mohammed Sarfraz Ahmed at 019 – 974 – 2770 Supervisor:- Br. Ibrahim Adham bin Taib at 019 – 370 – 4778 At regular business hours including weekends and holidays. Date _______________
Page 3 of 5
Participants Initials ______
Contact:Student Investigator :- Mohammed Sarfraz Ahmed at 019 – 974 – 2770 room number Mahallah Zahrawi boys hostel F 2.7. Research Supervisor :- Br. Ibrahim Adham bin Taib at 019 – 370 – 4778 Lecturers room _____________ On regular business hours including holidays and weekends.
Consent :I have read this form and the research study has been explained to me. I have been given the opportunity to ask questions and my questions have been answered. If I have additional questions, I have been told whom to contact. I agree to participate in the research study described above and will receive a copy of this consent form. I will receive a copy of this consent form after I sign it. __________________________________________________ Subject’s Name (printed) and Signature
_______________ Date
__________________________________________________ Name (printed) and Signature of Person Obtaining Consent
Date _______________
Page 4 of 5
Participants Initials ______
RESEARCH PARTICIPANT DETAILS “Electromyography of Rubber Tapper Tools” 1
Name
2
Age
3
Sex
4
Height
5
Weight
6
Hand Dominance
7
Occupation Details.
Date _______________
Page 5 of 5
Participants Initials ______
RESEARCH PARTICIPATION CONSENT FORM Project Title :- “Electromyography study of different rubber tapper tools” Student Investigator :- Mohammed Sarfraz Ahmed Project Supervisor :- Br. Ibrahim Adham bin Taib
Introduction/Purpose: The objective of this study is to assess the comfort and efficiency of the various rubber tapper tools that are being used today employing the use of the Electromyography. You are being requested to participate in this research study: The participant would represent the rubber tapper worker. To perform the same procedure of rubber tapping in a laboratory conditions. The purpose of this study : Is to determine whether the tools used by rubber tappers are contributing to any problems of the hand , wrist , and forearm . To identify which muscles of the forearms are being used during the actual rubber tapping process. To provide information that may aid in the designing of more ergonomically designed tools for carrying out the rubber tapping process. The Number of people involved in this research : 10 Male and 10 Females randomly selected. Procedures :As a participant of this study you will be requested to come to the physiology lab in the biolabs building on the first floor. Your participation in this study would last approximated 20 to 30 minutes and will require just one visit to the lab. 1. Before conducting the experiment you will be asked to fill out a questionnaire that has questions of a non personal nature such as Date _______________
Page 1 of 5
Participants Initials ______
a. b. c. d.
You will be required to fill out your full name. You will be required to indicate whether you are right or a left handed person. You will be asked about your height and weight. You will be required to explain your occupation.
2. You will be asked to perform the rubber tapping process after an explanation from the student investigator. 3. Electrodes that are attached to an electromyography device would be placed on certain muscles of the forearm. 4. Once the electrodes are attached you will perform the rubber tapping process using the rubber tapping tools on two surfaces that would represent the tree. 5. As you are performing the process the readings shall be recorded and documented for later data analysis. At any time in the study, you may decide to withdraw from the study. If you withdraw no more information will be collected from you. When you indicate you wish to withdraw the investigator will ask if the materials already collected in the study can be used. Risks & Discomfort You may get tired while performing the process and get rest at any time. You may feel a little bit awkward when holding the rubber tapping tool , you will be instructed on how to minimize this. The student investigator shall inform you any risks or complications if any associated with your participation in this research.
You have the right to withdraw from the study at any time. Research Related Injuries Immediate necessary medical care is available at the IIUM CLINIC in the event that you are injured as a result of participation in this project. However , there is no commitment by International Islamic University, Student Investigator and his supervisor to provide monetary compensation to you in the event of a project-related injury. For questions about the study or research related injury please contacts the student investigator Sarfraz at 019-974-2770 during regular business hours including weekends and holidays. Benefits There will be no direct benefit to you as a result of participating in this study Your participation in this study may :-
Date _______________
Page 2 of 5
Participants Initials ______
The data gathered as a result of your participation will help identify the risks associated with using the common rubber tapper tools in the Rubber Tapping industry in Malaysia. This data will assist in the future designing of more comfortable and ergonomic tools. This data will help alleviate the risk of injury for approximately 100,000 rubber tappers in Malaysia. Alternatives You have the alternative to choose not to participate in this study. Confidentiality Participation in this study may result in a loss of privacy , since persons other than the investigators might view the data gathered from this experiment. Unless required by law , only the student investigator and his supervisor will have the right to review the data gathered from the experiment. They are required to maintain the confidentiality regarding your identity. Results of this study may be used for teaching , research , publications or presentations at scientific meetings. If your individual results are to be discussed , your identity will be protected by giving a code rather that your name or other identifying information. Financial Information Your participation in this study will involve no costs to you. You will not be paid for your participation in this study. Participation and Withdrawal You can choose whether to be in this study or not. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. You may exercise the option of removing your data from the study. You may also refuse to answer any questions you don’t want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise that warrant doing so. Rights of Research Participations You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims or rights because of your participation in this research study. If you have questions regarding your rights as a research participant, contact Student Investigator: - Mohammed Sarfraz Ahmed at 019 – 974 – 2770 Supervisor:- Br. Ibrahim Adham bin Taib at 019 – 370 – 4778 At regular business hours including weekends and holidays. Date _______________
Page 3 of 5
Participants Initials ______
Contact:Student Investigator :- Mohammed Sarfraz Ahmed at 019 – 974 – 2770 room number Mahallah Zahrawi boys hostel F 2.7. Research Supervisor :- Br. Ibrahim Adham bin Taib at 019 – 370 – 4778 Lecturers room _____________ On regular business hours including holidays and weekends.
Consent :I have read this form and the research study has been explained to me. I have been given the opportunity to ask questions and my questions have been answered. If I have additional questions, I have been told whom to contact. I agree to participate in the research study described above and will receive a copy of this consent form. I will receive a copy of this consent form after I sign it. __________________________________________________ Subject’s Name (printed) and Signature
_______________ Date
__________________________________________________ Name (printed) and Signature of Person Obtaining Consent
Date _______________
Page 4 of 5
Participants Initials ______
RESEARCH PARTICIPANT DETAILS “Electromyography of Rubber Tapper Tools” 1
Name
2
Age
3
Sex
4
Height
5
Weight
6
Hand Dominance
7
Occupation Details.
Date _______________
Page 5 of 5
Participants Initials ______
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