PART 1: RESPONDENTS DETAILS |
Name...............................................................Sex....M/F Age...........Years. |
Occupation........................................................ Level of education........................................ |
Location/Residence............................................................................................................................... |
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Efficacy/Toxicity Data |
Type of Plant (Local name).......................................................................................... |
Preparation method(s).......................................................................................... |
Administration form (s).......................................................................................... |
Part(s) of plant used.......................................................................................... |
Used on : Humans................................... Animals/Species......................................... |
Route(s) of application.......................................................................................... |
Approximate dosage.......................................................................................... |
Response of Patient Good.........................Fair........................ Poor......................... |
Duration of response Seconds......................... Minutes......................... Hours......................... |
Complications |
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PART 2: RESPONDENTS CONSENT AGREEMENT |
I.......................................................................................Hereby agree to participate in this study with my full consent and conscious and declare that to the best of my Knowledge the information that I have provided is true, accurate and complete. |
Signature/Thumb print...........................................Date............./May/2007 |
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PART 3: RESEARCHER'S DECLARATION |
1. The following research will be undertaken with respect to the indigenous knowledge and intellectual proprietary of the Samburu Community. |
2. We will at no given time initiate or conduct practices that are deemed to obtain information from the respondents by intimidation, coercion or false pretence. |
3. The respondents will be informed of the intended project elaborately prior to questionnaire administration and in confidential to eliminate any degree of conspiracy. |
4. We will be no under any obligation to edit or tamper the information provided by the respondents. |
5. Translation and transcription will be necessary for clarification due to the language barrier. |
6. The information collected will be used for the described research purpose and not any undisclosed any undisclosed intentions. |
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Signatory Researchers: |
1. Dr. Nanyingi M.O..................2. Dr. Ogara O.W..................3. Dr. Mbaria J.M.................. |