CONSENT FORM FOR PARENTS(SURVEY/PHOTOGRAHPS)
Stanford Institutes of Medicine Summer Research Program 2008
FOR QUESTIONS ABOUT THE SCIENCE PROGRAM, CONTACT:
Faculty Director: Dr. P.J. Utz, 269 Campus Drive; CCSR-2215, Stanford, CA 94305,
(650) 724-6743
or
Program Director: Ms. Cindy Limb, 269 Campus Drive; CCSR-2250, Stanford, CA 94305
(650)724-6743.
DESCRIPTION: Your son or daughter has been selected to participate in our Stanford Institutes of Medicine Summer Research Program (SIMR). He/she is invited to participate in a research study (taking a pre- and post-survey) about the SIMR program. This program is funded by various sources (Howard Hughes Medical Institute, Arthritis Foundation, Genentech and other donors) for high-school students interested in medicalresearch. The goal of the SIMR program is to develop broad educational initiatives for clinical immunology, aimed at high school juniors and seniors. The program gives students an opportunity to participate in hands-on medical research and to be mentored directly by scientists. As a long-term goal, we hope that students will be encouraged to pursue careers in the biomedical field. In order to keep in touch with your son or daughter after the program is over, as well as to provide information about the SIMR Summer internsas a group to people who fund our program, we keep his/her original application and supporting documents on file. In addition, we ask your daughter or son to complete a short survey about his/her background. These files are kept in the SIMR office in a locked file cabinet and the only people who have access to them are SIMR staff members and employees.
RISKS AND BENEFITS: The risks associated with this program are minimal. The benefits which may reasonably be expected to result from this program for your son or daughter are:
- Interacting with Stanford scientists and professionals interested in mentoring students.
- Gaining a higher level of understanding about the scientific process.
- Learning more about opportunities in your community for students interested in scientific and health careers.
We do not think that collecting brief information about your daughter’s or son’s background (such as her/his age or parent’s occupations) will pose any risk for you. The benefit to the program is that we can provide evidence to our funders that the program is reaching a population of high school students who can benefit from learning about medical research. We cannot and do not guarantee or promise that your son or daughter will receive any benefits from this study.Your decision whether or not to allow your son or daughter to participate in this program will not affect your student status or schooling.
TIME INVOLVEMENT: Your son or daughter has already filled out the application. The survey for additional information will take approximately 15-20 minutes at the beginning of the program and 15-20 minutes at the end of the program, and will be done during the time he/she is on campus for the 8-week Summer Program.
PAYMENTS:You son or daughter will not receive any payment for participation in this survey. However, he/she will be receiving a $1500 stipend for participation in the program. In addition, all program supplies and lab supplies are free.
SUBJECT'S RIGHTS: If you have read this form and have decided to allow your daughter or son to participate in this project, please understand that his/her participation is voluntary and you or your child have the right to withdraw your consent or discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled. He or she has the right to refuse to answer particular questions during the survey that we give at the beginning and end of the summer to evaluate what you have learned. Your daughter’s or son’s individual privacy will be protected in all published and written data resulting from the study.
CONTACT INFORMATION:
Questions, Concerns, or Complaints: If you have questions, concerns, or complaints about this research study, its procedures, risks and benefits, or alternative courses of treatment, you should ask the Protocol Director, Dr. P.J. Utz. You may contact him now or later at: (650) 724-5421. You should also contact him at any time if you feel that you have been hurt by being a part of this study.
Independent Contact: If you are not satisfied with how this study is being conducted, or if you have any concerns, complaints, or general questions about the research or your your rights as a participant, please contact the Stanford Institutional Review Board (IRB) to speak to someone independent of the research team at (650) 723-5244 or toll free at 1-866-680-2906. You can also write to the Stanford IRB, Stanford University, Stanford, CA 94305-5401.
PHOTOGRAPHS: It is possible that pictures taken of your child and other program participants during activities such as attending lectures, working in the lab, or in other activities will be used in printed or in online content. To the extent possible, you will be given copies of these photographs to keep for your own use.
I give consent for my daughter or son to be photographed during this program:
Please initial: ______Yes ______No
I give consent for photographs resulting from this program to be used for extending knowledge about teaching students about the scientific process.
Please initial: _____Yes _____No
Please print out an extra copy of this consent form and keep it for your records.
PARENTS’ SIGNATURE ______DATE ______
Protocol Approval Date: September 28, 2007
Protocol Expiration Date: September 27, 2008
CONSENT FORM FOR STUDENTS
Stanford Institutes of Medicine Summer Research Program (SIMR)
FOR QUESTIONS ABOUT THE SCIENCE PROGRAM, CONTACT:
Protocol Director: Dr. P.J. Utz, 269 Campus Drive; CCSR-2215, Stanford, CA 94305,
(650) 724-6743
or
Program Director: Ms. Cindy Limb, 269 Campus Drive; CCSR-2250, Stanford, CA 94305
(650)724-6743.
DESCRIPTION: You have been selected to participate in our Stanford Institutes of Medicine Summer Research Program (SIMR).You are invited to participate in a research study (taking a pre- and post-survey) about the SIMR program. This program is funded by various sources (Howard Hughes Medical Institute, Arthritis Foundation, Genentech and other donors) for high-school students interested in medical research. The goal of this program is to develop broad educational initiatives for clinical immunology, aimed at high school juniors and seniors. The program gives students an opportunity to participate in hands-on medical research and to be mentored directly by scientists. As a long-term goal, we hope that students will be encouraged to pursue careers in the biomedical field. In order to keep in touch with you after you leave, as well as to provide information about the SIMR Summer internsas a group to people who fund our program, we keep your original application and supporting documents on file. In addition, we ask you to complete a short survey about your background. These files are kept in the SIMR office in a locked file cabinet and the only people who have access to them are SIMR staff members and employees.
RISKS AND BENEFITS: The risks associated with this program are minimal. The benefits which may reasonably be expected to result from this program are:
- Interacting with Stanford scientists and professionals interested in mentoring students.
- Gaining a higher level of understanding about the scientific process.
- Learning more about opportunities in your community for students interested in scientific and health careers.
We do not think that collecting brief information about your background (such as your age or parent’s occupations) will pose any risk for you. The benefit to the program is that we can provide evidence to our funders that the program is reaching a population of high school students who can benefit from learning about medical research. We cannot and do not guarantee or promise that you will receive any benefits from this study.Your decision whether or not to participate in this program will not affect your student status or schooling.
TIME INVOLVEMENT: You have already filled out the application. The survey for additional information will take approximately 15-20 minutes at the beginning of the program and 15-20 minutes at the end of the program, and will be done during the time you are on campus for the 8-week Summer Program.
PAYMENTS:You will not receive any payment for participation in this survey. However, you will be receiving a $1500 stipend for participation in the program. In addition, all program supplies and lab supplies are free.
SUBJECT'S RIGHTS: If you have read this form and have decided to participate in this project, please understand your participation is voluntary and you have the right to withdraw your consent or discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled. You have the right to refuse to answer particular questions during the survey that we give at the beginning and end of the summer to evaluate what you have learned. Your individual privacy will be protected in all published and written data resulting from the study.
CONTACT INFORMATION:
Questions, Concerns, or Complaints: If you have questions, concerns, or complaints about this research study, its procedures, risks and benefits, or alternative courses of treatment, you should ask the Protocol Director, Dr. P.J. Utz. You may contact him now or later at: (650) 724-5421. You should also contact him at any time if you feel that you have been hurt by being a part of this study.
Independent Contact: If you are not satisfied with how this study is being conducted, or if you have any concerns, complaints, or general questions about the research or your rights as a participant, please contact the Stanford Institutional Review Board (IRB) to speak to someone independent of the research team at (650) 723-5244 or toll free at 1-866-680-2906. You can also write to the Stanford IRB, Stanford University, Stanford, CA 94305-5401.
PHOTOGRAPHS: It is possible that pictures taken of you and other program participants during activities such as attending lectures, working in the lab, or in other activities will be used in printed or in online content. To the extent possible, you will be given copies of these photographs to keep for your own use.
I give consent to be photographed during this program:
Please initial: ______Yes ______No
I give consent for photographs resulting from this program to be used for extending knowledge about teaching students about the scientific process.
Please initial: _____Yes _____No
Please print out an extra copy of this consent form and keep it for your records.
STUDENTS’ SIGNATURE ______DATE ______
Protocol Approval Date: September 28, 2007
Protocol Expiration Date: September 27, 2008
Stanford Institutes of Medicine Summer Research Program (SIMR) Page 1 of 4