INFORMED CONSENT
Doll Recipient
I, ___________________________________, (the healthcare power of attorney, guardian, or a
responsible party) agree to allow __________________________________(resident) to take part
in doll therapy to decrease agitated behaviors. The project is being done by Jechell Lary-Waller,
who can be reached at 478-390-3836 or Jechell.larywaller@bobcats.gcsu.edu. I understand that
this is voluntary. I can revoke consent at any time and the data will not be used in the study.
I understand the following:
1. The purpose of this project is to use a doll to lower problem behaviors in residents with
dementia.
2. If the resident reaches, asks for, or accepts the doll, I will offer a doll to them.
3. Their names will not be on any papers. All information is private.
4. You will be asked to sign two consent forms. You must return one form to me before I
offer the resident the doll. You may keep the other consent form for yourself.
5. No questions are personal.
6. This project is being conducted because it may help the resident or someone like the
resident. The benefits of this study will be to help others with behavior problems in other
nursing homes or long-term areas. Doll therapy may help decrease agitation and stress for
the resident.
7. The resident is not likely to experience harm from receiving a doll.
8. The resident’s reaction to the doll will be kept private and will not be given to anyone
without your consent.
9. I will answer any questions you may have now or in the future (my phone number and
email are at the top).
10. If you want to know how the resident responded to the doll, I will provide it for you as
soon as possible.
11. By signing and returning this form, you are 18 years old or older and responsible for the
resident.
Signature of Investigator ____________________________________ Date ___________
Signature Healthcare Power of Attorney, Guardian, or a Responsible Party Date
Research at Georgia College involving human participants is carried out under the oversight of
the Institutional Review Board. Address questions or problems regarding these activities to the
GC IRB Chair, email: irb@gcsu.edu.
