Permission to Take Part in a Human Research Study Page 3 of 3
Title of Research Study: Social skills in home schooled versus conventionally educated children
Investigator: John Q Scholar, PhD
Supported By: Northwestern University
Why is my child being asked to take part in this research study?
We are asking your child to take part in this research study because they are between the ages of 9-10 years old.
What should I know about a research study?
· Someone will explain this research study to you.
· Whether or not you take part is up to you.
· You can choose not to take part.
· You can agree to take part and later change your mind.
· Your decision will not be held against you.
· You can ask all the questions you want before you decide.
Who can I talk to?
If you have questions, concerns, or complaints, or think the research has hurt your child, talk to the Principal Investigator, John Q Scholar, at (847) 123-4567.
This research has been reviewed and approved by an Institutional Review Board (“IRB”). You may talk to them at (312) 503-9338 or if:
· Your questions, concerns, or complaints are not being answered by the research team.
· You cannot reach the research team.
· You want to talk to someone besides the research team.
· You have questions about your rights as a research participant.
· You want to get information or provide input about this research.
Why is this research being done?
The purpose of this research is to learn more about social skill development in home schooled children and conventionally educated children.
How long will the research last?
We expect that your child will be in this research study for 45 minutes.
How many people will be studied?
We expect about 100 children will be in this research study.
What happens if I say “Yes, I want my child to be in this research”?
· You and your child will be asked to come to the Center for Child Studies on the Evanston campus of Northwestern University.
· Your child will be asked to fill out a standardized questionnaire about their thoughts and behavior in social situations. This will take about 20 minutes to complete.
· After a short break, your child will then be asked to take part in an unstructured group conversation with three other participants their age. The conversation will last for 20 minutes and will be video recorded for analysis purposes only. If you or your child does not agree to the video recording, it will not be possible to participate in this study. A member of the research team will be observing the video recording from another room as the conversation is occurring.
What happens if I do not want my child to be in this research?
You may decline to allow your child to participate and it will not be held against you.
What happens if I say “Yes”, but I change my mind later?
Your child can leave the research at any time and it will not be held against you.
At any time, you may decide to withdraw your child from the study. If you withdraw them, no more information will be collected from your child. When you indicate you wish to withdraw, the investigator will ask if the information already collected from your child can be used.
Is there any way being in this study could be bad for my child?
Your child could be uncomfortable being video recorded. If this happens, they are free to leave the research at any time. If any participant is behaving inappropriately to other children during the group conversation, the researcher observing the recording will end the conversation task early.
What happens to the information collected for the research?
Efforts will be made to limit the use and disclosure of your child’s personal information, including research study records, to people who have a need to review this information. We cannot promise complete secrecy. Organizations that may inspect and copy your information include the IRB and other representatives of this institution. The video recorded conversation is for data analysis purposes only. It will not be used in any presentations or publications.
We will not ask about child abuse, but if your child tells us about child abuse or neglect, we are legally obligated to report it to state authorities.
What else do I need to know?
Your child will be paid $10 for their participation in this study. We will also reimburse you $10 (if taking public transportation) or a free parking pass (if driving) to cover the costs of your transportation. Both payments will be given directly to you.
If for any reason your child does not complete the whole study, you will still receive the full payment and travel reimbursement.
[Note: include this paragraph if the study is taking place in a school:
Parents please be aware that under the Protection of Pupils Right Act 20 U.S.C. Section 1232 (c)(1)(A), you have the right to review a copy of the questions asked of or materials that will be used with your students. If you would like to do so, you should contact <Name of PI> to obtain a copy of the questions or materials.]
Your signature documents your permission for the named child to take part in this research.
______________________________________________________ __________________
Signature of child Date
______________________________________________________
Printed name of child
______________________________________________________ __________________
Printed name of parent [ ] or individual legally authorized [ ] Date
to consent for the child to participate
______________________________________________________ __________________
Signature of parent [ ] or individual legally authorized [ ] Date
to consent for the child to participate
______________________________________________________ ____________________
Signature of person obtaining parent permission and assent Date
______________________________________________________
Printed name of person obtaining parent permission and assent
Document Template Revision Date: September 24, 2015