Format For Signed Informed Consent Document (Page 3 of 4) in pdf

research is done properly. We would only permit people who are authorized by

organizations such as the Northeastern University Institutional Review Board [or

if applicable the sponsor or funding agency e.g. NIH, NSF, FDA, OHRP] to see

this information.

If I do not want to take part in the study, what choices do I have?

For treatment studies, alternatives to participation must be identified and described. For

example, if the person does not want to participate in an experimental physical therapy

program, inform the person about standard physical therapy or other appropriate health

care.

If your study does not involve treatment or other potential benefit, the participant’s option

is to not participate. In that case, you may omit this section.

What will happen if I suffer any harm from this research?

If research-related injury (i.e. physical, psychological, social, financial or otherwise) is

possible in research, provide an explanation of whatever compensation or treatment will

be provided. If physical injury is possible, explain whether any medical treatment is

available, what it consists of, and where further information may be obtained.

When appropriate, you may use wording such as, No special arrangements will be made

for compensation or for payment for treatment solely because of my participation in this

research.

Can I stop my participation in this study?

Ex: Your participation in this research is completely voluntary. You do not have

to participate if you do not want to. Even if you begin the study, you may quit at

any time. If you do not participate or if you decide to quit, you will not lose any

rights, benefits, or services that you would otherwise have [as a student,

employee, etc].

Who can I contact if I have questions or problems?

Include the name and viable contact information of one or more appropriate people. If

there is a possibility of an emergency, be sure an immediate response is available.

Who can I contact about my rights as a participant?

Ex: If you have any questions about your rights in this research, you may contact

Nan C. Regina, Director, Human Subject Research Protection, 960 Renaissance

Park, Northeastern University, Boston, MA 02115. Tel: 617.373.4588, Email:

irb@neu.edu. You may call anonymously if you wish.

Will I be paid for my participation?

If participants will be paid or given a gift, state what the payment is and when it will be

given.

Ex: You will be given a $5 gift certificate to Chicken Lou’s as soon as you

complete the Nutritional Quality of Life Survey.

NU HSRP Rev. 1/4/2010

TEMPLATE 1 - FORMAT FOR SIGNED INFORMED CONSENT DOCUMENT

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