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[TEMPLATE REMOVE after creating form]
Informed Consent Form
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: The purpose of this research is to
[Provide a brief summary of the purpose of the study in this section of the consent form. All wording must be at an 8th grade reading level or below. Someone familiar with your research should easily understand the consent document. Technical language must be avoided. If applicable, include how the subjects have been chosen and the number of participants that will be involved in the study. The informed consent form needs to be written in the second person.]
Procedures to be followed: You will be asked to...
[In simple, non-technical language, indicate all procedures that will require the participant's involvement and indicate any procedures that would be considered experimental. This includes the use of any audio/visual tape recording(s).]
Discomforts and Risks: [For example]: There are no risks in participating in this research beyond those experienced in everyday life. Some of the questions are personal and might cause discomfort.
[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. If there is a risk of potential injury or untoward events, include clear instructions on the protocol to be followed including notifying the researcher and, if the researcher is a student, the faculty advisor. This should include contact information and a specific time frame within which the notification must be made.]
Benefits: The benefits to you include...
The benefits to society include...
[In lay terms, describe any reasonably foreseeable benefits to the participant and/or others. If there are really none for either the participant and/or others, state such.]
Duration/Time:
[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 participation in this research is confidential. 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.
[Explain the extent to which participant records and data will be held confidential. For example, describe if code numbers and pseudonyms will be used and the storage/security of data. Explain who will have access to participants identity and access to the data.]
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.
[This paragraph should explain whom to contact for answers to pertinent questions about the research, research participation and whom to contact in the event of a research-related injury. Include phone numbers where investigators may be reached on a 24 hour basis. If applicable, include a statement that significant new findings developed during the course of the research which may relate to the participant's willingness to continue in the study will be provided. Additionally, referral information (including a phone number) for those who wish to seek assistance should also be included (e.g., the Engle Center).]
Payment for participation:
[Explain any compensation that will be provided to participants]. PLEASE NOTE: If participants will not be compensated, delete this Item (#8).
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, delete this Item (#9).
Voluntary Participation: Your decision to be in this research is voluntary. You can stop at any time. You do not have to answer any questions you do not want to answer. Refusal to take part in or withdrawing from this study will involve no penalty or loss of benefits you would receive otherwise.
You must be 18 years of age or older to consent to take part in this research study. If you agree to take part in this research study and the information outlined above, please sign your name and indicate the date below.
You will be given a copy of this consent form for your records.
__________________________________________
Printed Name
_____________________________________________ _____________________
Participant Signature Date
The informed consent procedure has been followed.
_____________________________________________ _____________________
Person Obtaining Consent (Investigator) Date
Page PAGE 1 of NUMPAGES 2
IRB USE ONLY: Project #
Ӱ
Institutional Review Board
Office of the Provost
Approval Date:
Expiration Date:
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