This form must not be distributed to participants until formal IRB approval has been received.
This sample consent form contains the minimum elements, which the IRB requires for the use of human participants in research. Different consent form designs may be used, but your form must address ALL of the following items. Please provide the information indicated in parentheses, and review the consent form check list to ensure that your consent is complete.
CONSENT FORM
I agree [or give my consent for (child's name)] to participate in the research project entitled (title of research), which is being conducted by (name of investigator, business address, and telephone number; student investigators may use their own information or that of their faculty advisor). I understand that this participation is voluntary; I can withdraw my consent [or I or my child can withdraw consent] at any time and have the results of the participation returned to me, removed from the experimental records, or destroyed.
The following points have been explained to me [and my child]:
1. The reason for the research is (give a short justification) and the benefits that I may expect from it are: (list specific benefits to the participant, if any; if none, so indicate)
2. The procedures are as follows: (describe the course of action that will happen to the participant, including time and place. In clinical studies involving experimental treatments, identify parts that are new or experimental, and indicate how they differ from other procedures that could be followed. Include a statement regarding the amount of time you expect it will take participants to complete assigned tasks.)
3. The discomforts or stresses that may be faced during this research are: (if none, so indicate)
4. Participation entails the following risks: (list all potential physical, psychological, social, or legal risks. If there are no known risks, so indicate. If risks exist, list the steps to be taken if harm should come to the participant, including any availability of medical treatment if needed)
5. The results of this participation will be (either anonymous, or if identifiable information is collected, the study will be confidential) and will not be released in any individually identifiable form without the prior consent of the participant unless required by law. (Describe procedures that will be used to ensure anonymity or confidentiality. If you are including an online survey in your study, state whether or not IP addresses will be collected.)
__________________________________________________
Signature of Investigator, Date__________________________________________________
Signature of Participant [or authorized representative], Date
(The following page removal note and IRB contact information must be included on all consent forms. Please include a dividing line as shown below.)
___________________________________________________________________________________________________