Informed Consent Research Study

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Informed Consent
To whom this may concern,
My name is Rachel Hutton and I am a student at Tennessee State University working on a B.S. degree in Health Science with a concentration in physical science. I am conducting a research study about whether or not Physical Therapist benefits people with chronic diseases. Please read the consent form carefully before you decide to participate in this study.
Purpose of the research study:
The purpose of this research study is to determine through statistical evidence that physical therapist do or do not play a major role in helping patients with chronic diseases.
What you will be asked to do in the research study:
Your participation in this research study will only take about 10-15 minutes of your
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If for any reason you choose not to participate or to withdraw from the study, you have the right to do so. The results of the research study may be published but your identity will remain confidential and your name will not be disclosed to any outside party. Although this research study may not benefit you, a possible benefit of your participation will give a better understanding to whether or not physical therapist do play an important role in helping patients with chronic diseases.

Whom to contact if you have any question about the study:
Please call Rachel Hutton at 615-975-2829 or email
If you wish to participate in this research study, please sign the form below. Your signature verifies that you agree to participate in the research study for Physical Therapists role in Chronic Diseases. Also, by signing below you are at least 18 years or older.

Signature of research participant___________________________ Date
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o Yes, how? _______________________________________________________________ o No, why not? ____________________________________________________________

Please answer the following questions by circling either strongly agree, agree, neither, disagree or strongly disagree. Over the past 6 months or most recent visits in receiving physical therapy treatment care for your chronic condition, you were…. 1
Agree 2
Agree 3
Neither 4
Disagree 5
Strongly Disagree
1 Given choices about treatment options to think about SA A N D SD
2 Given a written list of things to help improve health SA A N D SD
3 Satisfied and care was well organized SA A N D SD
4 Given a copy of treatment plan SA A N D SD
5 Asked how your chronic condition affects your life SA A N D SD
6 Asked how your visits were going (pain or discomfort) SA A N D SD

Thank you for your
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