Project Consent Form printable pdf download

1. Project Consent Form – SAMPLE

Part I – Research Participant Information sheet:

A: Purpose of the study:

You are being asked to participate in a research study. The purpose of the study is:

(three sentence description of purpose)

You qualify for this study because you are a healthy adult.

Description of the research:

In the ….. Project, we will enroll xx… volunteers. You will be asked to complete a brief

questionnaire about your age, residence, work history, exposure to…(list of

chemicals)….

Once during the study, a blood sample will be taken to test for YYYY, and a urine

sample will be taken to determine levels of …... Any remaining unused blood and urine

will be discarded. The samples and the measurement results will be identifiable, that is

they will be labeled with a code number which may be linked to your name only on a

single master list kept by Dr. …. . No identifiers will be included in the analysis of the

results of this investigation. You will be informed by Dr. …. or one of the investigators

of the results of your testing and counseled about the significance of these results. As a

volunteer for this study, you may decide that you wish to make public the pooled results

of the study as a group or as individuals.

Costs/Reimbursements:

None

Potential risks and Discomforts:

Participation in this study will not expose you to any significant risks. Blood will be

collected by medical staff trained in appropriate blood drawing and safety procedures.

You may experience some minor discomfort and may develop a small black and blue

mark on your arm. There is also a small chance of infection from blood drawing. There is

little or no risk associated with collecting urine samples.

E: Potential Benefits

The direct benefits to you from participation in this study are knowledge about your own

blood and urine levels of those chemicals being studied in this project. You will also

Project Consent Form