Informed Consent Form For Parents/guardians Of Project Participants

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Informed Consent Form for Parents/Guardians of
Project Participants
This is a sample informed consent form and should be adapted to suit your particular project.
Please use tick boxes for the person signing the form to initial or tick (see template for consent
for participants appended to the application form).
Headed paper – clear identification of the University as the responsible institution
Project Title: (Exactly as it appears on your application form)
I agree that my child/person ………………………………………(full name of child/person) for
whom I am a guardian may take part in the above City University London research project. The
project has been explained to ................………..…….. and to me, and I have read the Participant
Information Sheet, which I may keep for my records.
I understand that agreeing to take part means that I am willing to allow
…………………………………………………………………(Principal Investigator) to:
(list all procedures – these might include things like:)
be interviewed by the researcher
allow the interview to be videotaped/audiotaped
provide samples of blood/urine/muscle tissue/saliva/faeces __ times at __ hour/day/week
intervals
participate in an exercise program for a period of __ weeks
complete questionnaires asking me about …..
make her/himself available for a further interview should that be required
take a trial medication __ times a day for __ weeks
use a computer to ….
allow the researchers to have access to his/her medical/academic records
Data Protection
This information will be held and processed for the following purpose(s): (list purposes)
I understand that any information ……………………………………. (full name of child/person)
provides is confidential, and that no information that could lead to the identification of any
individual will be disclosed in any reports on the project, or to any other party. No identifiable
personal data will be published. The identifiable data will not be shared with any other
organisation.
OR
The identifiable data will be shared with (list organisations). This organisation has made a written
agreement with the University to abide by the Data Protection Principles.
OR
I understand that …………………… (outline steps to be taken) will be done to protect
……………………’s (full name of child/person) identity from being made public.
AND/OR

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