ࡱ> Y[Xi  bjbj b{b{bL'} XX8D8$%f\\\\\%%%%%%%$')?%O@?%XX\\T% ^X8\\% % #i#\.if5#%j%0%=#,t*S`t*i#i#t*}# ?%?%%t* B : [TEMPLATE REMOVE after creating form] Parental Permission Form for Children in Research Ӱ Title of Project: [Provide title of research study] Principal Investigator: [Include contact information office/mailing Address, email address, telephone number] Advisor: [REMOVE if PI is not a student Include contact information Office/mailing address Email address, telephone number] Other Investigator(s): [REMOVE if there are no other investigators] Purpose of the Study: Your child has been invited to join a research study to look at ________________. Please take whatever time you need to discuss the study with your family and friends, or anyone else you wish to. The decision to let you child join, or not to join, is up to you. In this research study, we are investigating/testing/comparing/evaluating __________________. [The information here should be a clear and short description of the bottom line of the study. Hold details of the study until later in the document. Briefly give the subjects some background information about why this study is being done, this can inclue information about what is already known and what you hope to learn] Procedures to be followed: Your child will be asked to ___________________.[Describe exactly what subjects can expect. Explain what will happen during the study and how the study will work. Include everything that subjects will be asked to do. Describe all surveys and data collection instruments that subjects will experience. Indicate how long each survey or procedure will take and state how long (e.g. minutes, hours, days, months, until a certain event or endpoint) the subjects will be part of the study.] The investigators may stop the study or take your child out of the study at any time they judge it is in your childs best interest. They may also remove your child from the study for various other reasons. They can do this without your consent. [If appropriate, list any additional reasons why subjects might be taken off the study.] Your child can stop participating at any time. If your child stops he/she will not lose any benefits. Discomforts and Risks: [For example]: There are no risks in participating in this research beyond those experienced in everyday life. [In lay terms, describe any reasonably foreseeable risks or discomforts to the participant. A statement must be included to address specific unforeseeable risks, such as risks for women who are able to become pregnant when participants will be recruited from this population.] Benefits: It is reasonable to expect the following benefits from this research: ______________________. However, we cant guarantee that your child will personally experience benefits from participating in this study. Others may benefit in the future from the information we find in this study. Duration/Time: We think this will take him/her ___________minutes to complete the study. [Explain how much time (e.g., 1 hour, 30 minutes) will be required to complete participation in this research. Also explain the period of time during which this participation will occur and the number of sessions required.] Statement of Confidentiality: Your childs name will not be used when data from this study are published. Every effort will be made to keep clinical records, research records, and other personal information confidential. We will take the following steps to keep information confidential, and to protect it from unauthorized disclosure, tampering, or damage: The data will be stored and secured at (location) in a (locked/password protected) file. Ӱs Institutional Review Board for the Protection of Human Subjects, and the Department of Health and Human Services Office for Human Research Protections may review records related to this research study. In the event of a publication or presentation resulting from the research, no personally identifiable information will be shared. Right to Ask Questions: Please contact ______________ at (XXX) XXX-XXXX with questions, complaints or concerns about this research. You can also call this number if you feel this study has harmed you. Questions about your rights as a research participant may be directed to Ӱs Office of the Provost at (717-766-2511 x5375). You may also call this number if you cannot reach the research team or wish to talk to someone else. Payment for participation: [Explain any compensation that will be provided to participants]. PLEASE NOTE: If participants will not be compensated, state that there is no compensation for participating. Cost of participating: [Explain any additional costs that may result from participation in the research.] PLEASE NOTE: If no additional costs will result from participation, state that there is no cost incurred with participation. Voluntary Participation: Participation in this study is voluntary. Your child has the right not to participate at all or to leave the study at any time. Deciding not to participate or choosing to leave the study will not result in any penalty or loss of benefits to which your child is entitled, and it will not harm his/her relationship with _______________. If your child decides to leave the study, the procedure is: _____________________. [Describe procedures for withdrawing and any follow-up that you will request for subjects who withdraw early. Follow-up such as questionnaires that are part of the research cannot be forced upon subjects who wish to withdraw.] You will be given a copy of this consent form for your records. Permission for a Child to Participate in Research As parent or legal guardian, I authorize _________________________________ (childs name) to become a participant in the research study described in this form. 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