CONSENT FORM

Introduction :
Parents of children are requested to allow and participate in a study named
"Changing Epidemiology of Neonatal Sepsis " in Department of Pediatrics,
Institute of Medical Sciences, BHU, Varanasi. You and your child's participation in
this study is voluntary. You may refuse to allow your child to participate or withdraw
from the study without this affecting in any way the medical treatment that your child is
receiving. Please read this consent form thoroughly and ask any question you may have
about the study before signing.
Explanation of Procedures :
If you agree to allow to participate in this study, we will ask you some questions
from you and about your child and collect relevant information from his/her hospital
records. Interview method will be used for collection of data. Data from the study will
be used for research purposes. No incentives will be given for participation in the study.
Potential Benefits :
The participation of your child will help us in managing the children in a better
way and results of this study will be beneficial for future generations, and rehabilitation
program.
Assurance of Confidentiality :
The information concerning participation of your child in this study will be kept
confidential to the full extent permitted by law and used only for scientific purposes. No
one except members of the research team will have access to the test results. You and
your child's name will not be used in any report or released anyway.
Consent of Legally acceptable representative :
I have been explained the details of this study and have been given the
opportunity to discuss it and to ask questions. I, hereby, give consent to allow my child
to take part in the study.

________________ _______________ ___ ________________

Signature of Legally Signature of Witness Date
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lgefr nsrk gw¡A

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ds Ik'pku ey dk uewuk ,df=r djsaxsA ge vkids cPps ds Vhdkdj.k dkMZ dh ,d
izfr Hkh ysaxsA ftlls fd ;g irk py lds fd mls jksVkok;jl oSDlhu yxh gS ;k
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mlds bykt ds nkSjku] vLirky esa gksus okys lk{kkRdkj esa ge vkils dqN iz'u
iwNsaxs vkSj mlds gkLihVy jsdkMZ ls vko';ds vkadM+sa ,df=r djsaxsA bl
lk{kkRdkj ds ifj.kke rFkk rF;ksa dk iz;ksx 'kks/k ls lacaf/kr v/;;u ds fy, fd;k
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vkids cPps dh Hkkxhnkjh ls ge bZykt dks csgrj djus esa l{ke gks ldrs gSaA
xksiuh;rk %
vkids ejht dh Hkkxhnkjh ls lacaf/kr rF;ksa dks iw.kZr% xksiuh; j[kk
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'kadkvksa dk lek/kku dj fy;k gSaA eSa bl v/;;u esa Hkkxhnkjh ds fy,
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