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

Format For Signed Informed Consent Document Page 4

Will it cost me anything to participate?

State any costs that may be incurred by the participant for the study, e.g., parking.

Is there anything else I need to know?

Include any pertinent information that may not be stated elsewhere.

Ex: You must be at least 18 years old to participate unless your parent or

guardian gives written permission.

Ex: This research is paid for by Boston Police Dept; XYZ Pharmaceuticals;

Internal Revenue Service

I agree to [have my child] take part in this research.

____________________________________________

________________________

Signature of person [parent] agreeing to take part

Date

____________________________________________

Printed name of person above

____________________________________________

________________________

Signature of person who explained the study to the

Date

participant above and obtained consent

_____________________________________________

Printed name of person above

````````````````````````````````````````````````````````````````````````````````````````````````````````````

Depending upon the nature of your research, you are required to provide

information about one or more of the following if it is applicable:

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

(or to the embryo or fetus, if the subject is or may become pregnant) which are

currently unforeseeable.

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

by the investigator without regard to the subject’s consent.

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

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

procedures for orderly termination of participation by the subject.

5. A statement that significant new finding(s) developed during the course of the

research which may be related to the subject’s willingness to continue participation

will be provided to the subject.

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

NU HSRP Rev. 1/4/2010

TEMPLATE 1 - FORMAT FOR SIGNED INFORMED CONSENT DOCUMENT

Format For Signed Informed Consent Document Page 4