OAKLAND CITY UNIVERSITY
INFORMED CONSENT TO PARTICIPATE IN A RESEARCH PROJECT
The researcher is encouraged to model this consent
form to his or her specific needs. If the researcher chooses not
to use this format, the consent form must at a minimum include the
same elements as this model. Before using this model, delete all
text in brackets. Consent documents should be written in simple
language, so that they may be understood easily by people with all
levels of education. Due to the fact that special circumstances
and requirements are involved in obtaining the informed consent
of minors, students of public schools in the state of Indiana and
individuals with mental disabilities, a researcher that intends
to, or may utilize, such human subjects must consult with the IRB
and obtain the approval of the IRB for informed consent forms to
be utilized in such research activities prior to submitting the
Universal Research Application for such research activities.]
TITLE OF PROJECT:
NAME OF PRINCIPLE RESEARCHER
[Faculty Member or Student researcher]
NAME OF FACULTY ADVISOR
[If this is a student research project, otherwise delete this section]
CONTACT NAME AND PHONE NUMBER FOR QUESTIONS\PROBLEMS
ABOUT RESEARCH PROJECT:
CONTACT NAME AND PHONE NUMBER FOR QUESTIONS\PROBLEMS
ABOUT PERSON’S RIGHTS OR ETHICAL CONSIDERATIONS:
[IRB representative: Michelle Bryson 749-1202]
SPONSOR OF THE PROJECT:
[Funding Source, if applicable]
PURPOSE OF THE RESEARCH:
[Explain that the study involves research and describe its purpose]
PROCEDURES/METHODS TO BE USED:
[Use everyday language so participants clearly understand how the
study will be conducted and what will be expected of them. Explain
the techniques and procedures that participants will experience.
Identify and describe any experimental or non-standard procedures,
methods, drugs, or devices. Tell them if they will be videotaped
or audio-taped.]
RISKS INHERENT IN THE PROCEDURES:
[Describe any reasonably foreseeable risks to the participants.
Include any physical, psychological, social, economic, or legal
risks. If the research involves physical risks, include a statement
informing the subject that if she is or may become pregnant, the
particular research may involve risks to the subject or embryo,
which are currently unforeseeable. State “There are no known
risks: if there are none. ASLO include the following statement:
It is not possible to identify all potential risks in an experimental
procedure, but the researcher(s) have taken reasonable safeguards
to minimize any known and potential, but unknown risks.]
BENEFITS:
[Describe any benefits to the participants or to others that may
reasonably be expected for the research. Monetary compensation should
not be categorized as a benefit.]
ALTERNATIVE PROCEDURES:
[If applicable, inform the participant of any alternative ways to
achieve the same benefit that may or may not involve the same risks.]
COMPENSATION:
[Tell the participants if they will receive remuneration for participation
and under what conditions. If applicable, inform participants of
any costs to them that may result from participation in the study.]
CONFIDENTIALITY:
[Describe how confidentiality of the participants will be maintained.
When individual names will not be recorded except on the informed
consent form, and those names will not appear on the final document,
please consider using this standard statement: While one cannot
ever guarantee complete confidentiality, reasonable steps will be
taken to prevent anyone from associating participants’ names
with the data gathered. The individual names of research participants
will not appear on any of the papers on which the data are recorded,
nor will they appear in the final research document. The only place
the names of participants will appear is on this signed informed
consent form. The consent form will be stored separately from the
data and not linked to the data collected. In addition to the researchers,
the federal research regulatory bodies and the Oakland City University
Institutional Review Board may have access to the research records.]
OTHER CONSIDERATIONS:
[List any other considerations that may affect a person’s
willingness to participate. Inform the participant if the researcher
has a significant financial interest in the outcome of this particular
study of research. Inform the participants that there may be research
procedures that conflict with the participant’s beliefs or
values.]
PARTICIPATION:
[Include these paragraphs using all capital letters
and bold print with minimal modification. Do not have signatures
appear on a page without this text.]
YOUR PARTICIPATION IN THE RESEARCH IS VOLUNTARY.
IF YOU DECIDE TO PARTICIPATE IN THE STUDY, YOU MAY WITHDRAW YOUR
CONSENT AND STOP PARTICIPATING AT ANY TIME WITHOUT PENALTY OR LOSS
OF BENEFITS TO WHICH YOU ARE OTHERWISE ENTITLED. IF AT ANY TIME
DURING THE RESEARCH, THERE ARE NEW FINDINGS THAT MAY AFFECT YOUR
WILLINGNESS TO PARTICIPATE IN THE STUDY, YOU WILL BE INFORMED OF
THOSE FINDINGS.
Include a description of circumstances in which
the subject’s participation may be terminated by the investigator
without the subject’s consent.]
YOUR SIGNATURE ACKNOWLEDGES THAT YOU HAVE READ
OR HAVE HAD READ TO YOU THE INFORMATION STATED AND ARE KNOWINGLY
AND WILLINGLY SIGNING THIS CONSENT FORM. YOUR SIGNATURE ALSO ACKNOWLEDGES
THAT YOU HAVE RECEIVED, ON THE DATE SIGNED, A COPY OF THIS DOCUMENT
CONTAINING 2 PAGES.
______________________________
Participant’s Name (printed)
______________________________ ____________________
Participant’s Signature Date
______________________________ ____________________
Investigator or Co-investigator Date
[Use the following block only if parental\guardian consent is required.
Include the text explaining to what the parents are agreeing.]
FOR MINOR
As parent or guardian you authorize _________________________
(print name) to become a participant for the described research.
The nature and general purpose of the project have been satisfactorily
explained to you by _________________________ and you are satisfied
that proper precautions will be observed.
Minor’s date of birth: ________________________
_______________________________
Parent\Guardian Name (printed)
Parent\Guardian Signature ____________________________
Date __________________
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