Miami Dade College Informed Consent Form Template printable pdf download

Informed Consent Form Template

Miami Dade College Institutional Review Board

Based upon

HHS.gov

guidelines

Informed Consent

Title of Study

Purpose: Provide a statement that the study involves research and explain of the purpose of the research. Include a

brief description about how the data will be used.

Procedure: Provide a description of the procedures to be followed and identify any procedures which are

experimental. Provide an explanation of what participation in the study will entail and give the expected duration of

the subject’s participation. Provide a disclosure of appropriate alternative procedures or courses of treatment, if any,

that might be advantageous to the subject.

Risks: Provide a description of any reasonably foreseeable risks or discomforts to the subject. For research involving

more than minimal risk, provide 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. See Appendix A below for additional elements that are to be included in this section, if applicable.

Benefits: Provide a description of any benefits to the subject or to others which may reasonably be expected from the

research.

Confidentiality: Provide a statement describing the extent, if any, to which confidentiality of records identifying the

subject will be maintained.

Rights: Provide a clause stating that participation is voluntary, refusal to participate will involve no penalty or loss of

benefits to which the subject is otherwise entitled, and the subject may withdraw from the study at any time without

penalty or loss of benefits to which the subject is otherwise entitled.

Contact information: Provide an explanation of whom to contact for answers to pertinent questions about the

research and the subject’s rights, and whom to contact in the event of a research-related injury to the subject. At

minimum, this section must include the PI’s contact information. If Miami Dade College is the PI’s home institution,

this section should also include the following statement: “Please contact Miami Dade College’s IRB at

IRB@mdc.edu

you have any questions, complaints, or concerns regarding your rights as a research participant.”

Provide a statement of consent, such as “I have read and understood the information above, I voluntarily agree to

participate in this study, and I certify that I am 18 years of age or older. All of my questions have been answered, and I

have received a copy of this consent form.”

______________________________________________

_____________________

Participant Name

Date

______________________________________________

Participant Signature

______________________________________________

Participant Signature

Authorizing Audio/Video Recording (if applicable)

Miami Dade College Informed Consent Form Template