Study Participation Informed Consent Form

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Recommended Sample – complete the areas that are appropriate for your study – expand as needed!)
__________________________________
Your Name and School
Informed Consent Form
TITLE
You are invited to participate in a research study. The purpose if this study is to determine
…..(Explain).
INFORMATION
Methods to be used
(give
details).
Data will be analyzed …
(details of how data will be
analyzed).
The study will take place during
(give expected
dates).
Depending on the results, data may be used in further analysis by research scientists.
RISKS
Describe the risks.
BENEFITS
This project will ….
(state the intended
benefit).
CONFIDENTIALITY
The information in the study records will be kept confidential. Data will be stored securely and will be made available only to
persons conducting the study unless you specifically give permission in writing to do otherwise. No reference will be made in
oral or written reports which could link you to the study. No identifiers (name, age, etc.) will be disclosed to anyone, and all
information will be destroyed at the completion of the study.
CONTACT
If you have questions at any time about the study or the procedures, (or you experience adverse effects as a result of
participating in this study,) you may contact ….
(list Adult Sponsor/Qualified Scientist if one is involved, and the phone
number/e-mail address for participants to call
upon).
PARTICIPATION
Your participation in this study is voluntary; you may decline to participate without penalty. If you decide to
participate, you may withdraw from the study at any time without penalty.
CONSENT
I have read the above information, reviewed the questionnaire (if one is involved) and agree to participate in this study.
Participant's name (print) ___________________________________________
Participant's signature ______________________________________________ Date ______________
Parent/Guardian's name (print) ______________________________________
Parent/Guardian's signature _________________________________________ Date _______________

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