Irb Consent Form Template (Page 3 of 4) in pdf

1. A statement that the particular treatment or procedure may involve risks to the

participant (or to the embryo or fetus, if the participant is or may become

pregnant) which are currently unforeseeable.

2. Anticipated circumstances under which the participant’s participation may be

terminated by the investigator without regard to the participant’s consent.

“ You should also understand that the investigator has the right to withdraw you

from the research project at any time.” [Here indicate any anticipated

circumstances under which the volunteer’s participation may be terminated

without regard to the volunteer’s consent]”

3. Any additional costs to the participants that may result from participation in the

research.

4. The consequences of a participant’s decision to withdraw from the research and

procedures for orderly termination of participation by the participant.

5. A statement that significant new findings developed during the course of the

research which may relate to the participant’s willingness to continue

participation will be provided to the participant.

6. The approximate number of participants involved in the study.

(You should set up your word processor so that the information below appears on a single sheet

of paper.)

ACKNOWLEDGEMENT AND CONSENT

I, _______________________________________________________[Prospective Volunteer’s

Full Name] of ________________________[Street, Address, City, State, Zip

Code]__________________ hereby state:

1. I have read all of the statements above pertaining to the research project entitled [brief

title of the research project], and I understand them.

2. I have been given the opportunity to ask questions concerning this research project

[study, experiment, etc.], and any questions that I have asked have been answered to my

satisfaction.

3. I have been given a full copy, with signatures, of this document.

4. I hereby consent to be a volunteer in this research project [study, experiment].

_________________________________________________________________

Signature of Prospective Volunteer ---------------------------- Date

WITNESS:

______________________________________________________________

Signature of Witness ----------------------------------------- Date

As the investigator in the research project entitled [brief title of research project], I state to the

best of my knowledge and belief all of the statements made in the above consent form are true.

In consenting, the prospective volunteer exercised free power of choice without undue

Irb Consent Form Template Page 3