Appendix 10

Participant Identification Number:

Study Title: An exploratory study to ascertain the developmental and support

needs of the clinical nurse specialist in palliative care working in the community
within one hospice setting in Northern Ireland

Name of Researcher: ___________________________________

 I confirm that I have been given and have read and understood the
information sheet for the above study and have asked and received
answers to any questions I have raised

 I understand that my participation is voluntary and that I am free to

withdraw at any time without giving a reason

 I agree to my one to one interview being recorded

 I understand that the researcher will hold all information and data
collected securely and in confidence and that all efforts will be made to
ensure that I cannot be identified as a participant of the study. I also
understand that the information will be stored securely and destroyed
in accordance with the requirements of the Data Protection Act 1998
and University of Ulster policy.

 I agree to take part in the above named study

Name of Participant ____________Signature__________________

Date______

Name of Researcher____________Signature_________________
Date______

(When completed, one copy should be given to participant and one copy kept by researcher)