responsible for making arrangements for payment of the expense of such treatment. Further 
information may be obtained from Dorothy M. Maher, Division of Sponsored Programs, Office of the 
Vice President for Research (319) 335-2123. 
I understand that participation is 
(subject) 
voluntary, and I may withdraw my consent for him/her to take part at any time without penalty or 
loss of benefits to which he/she may be entitled. 
I hereby freely consent to . 
taking part in the research project. 
(subject's name) 
(legally authorized representative^ signature) (date) 
I, the undersigned, certify that I was present during the oral presentation of the written 
summary attached when it was given to the above legally authorized representative of the subject 
matter. 
(auditor-witness signature) 
(date) 
[188] 
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