被试知情同意书.docVIP

被 试 知 情 同 意 书 (RESEARCH CONSENT FORM) 姓名 (NAME) 性别 (GENDER) 出生日期 (DATE OF BIRTH) YYYY/MM/DD 身高 （Height） 体重 （Weight） 受教育程度 （Final Qualification） 国籍 (NATIONALITY) 身份证号 (ID) 课题题目 (Project Title) 身份 (Identity) 姓名 职称 (Name Title) 研究单位 （Institution） 主要研究者 (Principal Investigator) 合作研究者 (Co-Investigator) 合作研究者 (Co-Investigator) 合作研究者 (Co-Investigator) 合作研究者 (Co-Investigator) 合作研究者 (Co-Investigator) 合作研究者 (Co-Investigator) 合作研究者 (Co-Investigator) 被试类型 (Subject Population) 研究联系人 (Study Contact) 联系电话 （Telephone） Email: 研究目的(Purpose) 实验程序(Procedure) 费用(Costs) 本研究不会向您或您的医疗保险收取任何费用。(No charges will be billed to your insurance company or to you for this study.) 潜在风险和副作用(Risks and Side effects) 除去那些身上装有电子的、磁的或机械的设备（如心脏起博器）的人，或有颅内动脉夹者，已知的磁共振成像对人的危害或副作用非常小。最大的风险是受到磁场吸引的金属物体在其飞行运动中击中您。为了减少这种风险，我们要求所有参与研究的人在进入磁体间之前除去身上所有的金属物品。高速MRI无任何已知的风险。本研究将使用的扫描序列和扫描参数都是经美国食品和药品管理局审核并确认安全的。 (The known risks associated with conventional MRI procedures are minimal, except for those people who have electrically, magnetically or mechanically activated implants (such as cardiac pacemakers) or those who have intracerebral vascular clips. The greatest risk is of a metallic object flying through the air toward the magnet and hitting you. To reduce this risk we require that all people involved with the study remove all ferrous metal from their clothing and pockets before entering the magnet room. There are no other known risks associated with high-speed MRI. Both the conventional and the high speed MRI systems have been approved by the FDA and will be operated within the operating parameters reviewed and accepted by the FDA). 磁共振扫描不会产生不适，但若您对置封闭空间感到恐惧，请告诉实验主试。在实验中，您会听到类似敲击的声音，佩戴耳塞后，这些声音没什么影响。(A magnetic resonance scan is not uncomfortable but if you are prone to claustrophobia (i.e., fear of enclosed spaces) you should notify the researcher in charge of the scan. You can expect to hear a knocking sound during the imaging; ear plugs will be p