Irb Consent Form Template (Page 2 of 4) in pdf

6. [Availability of Compensation and Medical Treatment for Injury.]

NOTE: If there is no more than minimal risk, you may omit this entire paragraph. For

research involving more than minimal risk, an explanation as to whether any

compensation and an explanation as to whether any medical treatments are available if

injury occurs and, if so, what they consist of, or where further information may be

obtained. If compensation and medical treatment are not available, include the following

statement on the Acknowledgment and Consent page (the last page below):

“I understand that if I am injured, no form of compensation is available. Medical

treatment may be provided at my own expense or at the expense of my health care

insurer, which may or may not provide coverage. If I have questions, I should contact my

insurer.”

7. [Opportunities to Have Questions Answered.] An explanation of whom to contact for

answers to pertinent questions about the research and research participants’ rights, and

whom to contact in the event of an research-related injury to the participant [provide

name, telephone number and address]. For student research, the student investigator and

the faculty sponsor should be listed as contacts for information and reporting of injuries.

For all research, the Chair of the IRB should be listed as the contact for answers about

research participants’ rights. Any injury must be reported by the investigator to the Chair

of the IRB, within 48 hours of occurrence.

“Please be sure to ask me at this time any questions you may have about the procedures

to be used in this research project [experiment, etc.]; at any later time, you should also

feel free to ask any questions that occur to you.”

Add also: “If you have questions concerning your rights as a volunteer, you may contact

[name of Chair of IRB], Chair of the Beloit College Institutional Review Board, at [give

address and phone number]”

8. [Freedom To Withdraw Consent.] A statement that participation is voluntary, refusal to

participate will involve no penalty or loss of benefits to which the participant is otherwise

entitled, and the participant may discontinue participation at any time without penalty of

loss of benefits to which the participant is otherwise entitled.

“If you consent to be a volunteer in this research project [experiment, etc.], you are still

free to withdraw your consent and discontinue participation at any time without prejudice

to you.”

9. [Additional Elements as Appropriate.]

NOTE: If none of these apply, you may omit this entire paragraph. The most likely one to

be relevant is (b), where an example might be the failure of the volunteer to follow

instructions given to them by the investigator, where such failure might cause risk to the

participant or others or compromise the purposes of the research. Element (d) may apply

if participants are to be compensated in some way.

Irb Consent Form Template Page 2