Healthcare Workforce Burnout Research Consent Form
Please review the information below and provide your consent to participate in this research study on healthcare workforce burnout.
Participant Full Name
*
First Name
Last Name
Professional Role / Occupation
*
Please Select
Physician
Nurse
Allied Health Professional
Administrative Staff
Support Staff
Other
Department or Organization
*
Email Address
*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
By signing below, I confirm that I have read and understood the information provided about this study, and I voluntarily agree to participate.
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
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