CONSENT FORM TEMPLATE
TITLE OF STUDY (type it here)
Campus
Address:
Co-Investigators/Students:
[If there is selection criteria for the study, the following wording
should also appear in the first paragraph]
Investigational
Procedures
[Be
sure to describe what the participants will be asked to do and to estimate the
amount of time required of the participants in your study If you are conducting a survey or interview,
it is helpful to describe the type of questions and to even provide an example
of the questions to be asked..]
Risks and
Benefits
[If
the research is classified as having “minimal risk,” the following wording is
recommended.]
This investigational procedure does not pose any more risk than you experience in normal daily living. If you participate in this study, you may experience (…any potential benefits to the participant…) and the satisfaction that comes with research and discovery. We appreciate your assistance in our research effort and hope you will find the experience rewarding. We do not promise, however, that you will receive any of these benefits.
[If the research is classified as having “more
than minimal risk,” the following wording is recommended.]
Research studies often involve some risk. The risks of this
study are…(use plain language).
In addition, it is possible in any experiment that harmful
effects that are not known could occur.
Of course we will take every precaution to watch for and prevent any
side effects.
If you participate in this study, you may experience (…any
potential benefits to the participant…) and the satisfaction that comes with
research and discovery. We appreciate your assistance in our research effort
and hope you will find the experience rewarding. We do not promise, however,
that you will receive any of these benefits.
[If
it will be possible to trace a data record back to the participant, use the
following statement.]
Any information that we learn about you that can be traced to you will be used responsibly and will be protected against release to unauthorized persons.
[If
there will be no way to trace a data record back to the participant, as with an
anonymous survey, use the following statement.]
Although your data record is totally anonymous, be assured that the information you provide will be used responsibly and will be protected against release to unauthorized persons.
In addition to those who usually have access to this data (state who all that would be), your data record will likely be shown to members of the investigation team listed on this form. If you sign this form you have given us permission to release information to these persons. The results of this study may be published in the (select the one that applies -- professional, medical, educational) literature, but no publication will contain information that will identify you.
Payment
You will receive (identify amount of payment) for you
participation in this study.
OR
You will receive no payment for participating in this study.
Conclusion
[For
students, faculty, and staff:]
Your decision whether or not to participate in this study is voluntary and will not affect your standing at Lock Haven University of Pennsylvania.
[For
participants recruited from outside the University:]
Your decision to participate in the study is voluntary.
[Followed
by:]
Even if you decide to participate, you may stop and withdraw
at any time. Of course we will tell you
anything during the study that may help you decide whether to continue
participation. You are making a decision
whether or not you will participate in this study. If you sign this form, you will have agreed
that you will participate based on reading and understanding this form. If you have any questions, please ask one of
the investigators identified on the front of this form.
If you have any questions regarding research participants’ rights, please contact Dr. Christine Offutt, Chair, Lock Haven University Institutional Review Board for the Protection of Human Subjects at coffutt@lhup.edu or (570)484-2400.
You will receive an unsigned copy of this form.
Date_______________________
Participant Signature
Date_______________________
Member of Investigational Team
Signature