[2. Description, Including Risks and Benefits]
If you decide to participate, we (or and associates) will (Describe the procedures to be followed, including their purposes, how long they will take, and their frequency. Describe the discomforts and inconveniences reasonably to be expected, and estimate the total time required. Describe the risks reasonably to be expected, and any benefits reasonably to be expected.)
[3. Alternative Procedures]
(If applicable, describe appropriate alternative procedures that might be advantageous to the participant, if any. Any standard treatment that is being withheld must be disclosed.)
[3. Confidentiality]
Any information obtained in connection with this study that can be identified with you will remain confidential and will be disclosed only with your permission. In any written reports or publications, no one will be identified or identifiable and only group data will be presented. (If you will be releasing information to anyone for any reason, you must state the persons or agencies to whom the information will be furnished, the nature of the information to be furnished, and the purpose of the disclosure). This consent form, with your signature, will be stored separately from the data collected so that your responses will not be identifiable. (Note: If the study meets the criteria for basic status, it is permissible to give the subject the only copy of the consent form when it is the only form that identifies the subject and when retaining it would only create a possible loss of anonymity.)
[4. Compensation]
(If the participant will receive compensation, describe the amount or nature. If there is a possibility of additional costs to the participant because of participation, describe them. If there is a possibility of a research-related physical injury, information as to the medical treatment and compensation available should be included.)
[5. Statement that Participation is Voluntary]
Your decision whether or not to participate will not affect your future relations with the (institution or agency) in any way. If you decide to participate, you are free to discontinue participation at any time without affecting such relationships.
[6. Whom to contact for answers to questions]
If you have any questions, please ask us. If you have any additional questions later, we will be happy to answer them. Contact (name and phone number). You will be offered a copy of this form to keep.
[7. Signature indicating Informed Consent]
You are making a decision
whether or not to participate. Your signature indicates that you
are 18 years of age, have read the information provided above, and have
decided to participate. You may withdraw at any time without prejudice
after signing this form should you choose to discontinue participation
in this study.
| __________________________________________________
Signature of Participant |
__________________________________________________________
Date |
| _________________________________________________________
Signature of Parent of Legal Guardian (This line should not appear on forms that will be given to participants for themselves.) |
__________________________________________________________
Date |
| _________________________________________________________
Signature of Health Care Provider (This line should appear only when research involves participants who are under the care of such a person, and when the condition requiring care may interact with the research procedures.) |
___________________________________________________
Date |
| _________________________________________________________
Signature of Witness (when appropriate) |
__________________________________________________________
Date |
| _________________________________________________________
Signature of Investigator |
__________________________________________________________
Date |
Last updated: August, 2006
If you have any comments or suggestions about this web site, please send them to wsvelmoe@sainmarys.edu.
This site was authored by Dr. Catherine Pittman and Zhou Zhu as the product of a faculty / student special project.