Note to Researcher: This sample consent document contains the minimum elements of informed consent required by the IRB for use of human subjects in research. You may design your consent form in any format you wish, but you must include all of the required elements of consent. Please review the consent form checklist and remove all instruction notations in red from your finalized consent document. The child assent section should be modified to suit your study. See the assent document samples for age appropriate language.

PARENTAL CONSENT FORM WITH CHILD ASSENT STATEMENT

Title of Research Study:{insert title of study}

Researcher's Contact Information: Name, Telephone, and Email{students may use faculty advisor's contact information if desired}

Your child is being invited to take part in a research study conducted by {insert name of PI} of Kennesaw State University. Before you decide to allow your child to participate in this study, you should read this form and ask questionsif you do not understand.

Description of Project

The purpose of the study is {briefly describe the nature of the study and the purpose of the research in layman's language}.

Explanation of Procedures

{Briefly describe the course of action that will happen to the participant.}

Time Required

{Include a statement regarding amount of time expected to complete assigned tasks.}

Risks or Discomforts

{Explain any risks or discomforts - including psychological discomfort - that might reasonably be expected to happen, and list steps to be taken if harm should come to the participants, including any availability of medical treatment if needed. If there are no known risks or anticipated discomforts in this study, then state so.}

Benefits

{Briefly describe benefits to the subject or to others described in Question 4 of the IRB Approval Request form. If there are no direct benefits to the subject, include language stating that although there will be no direct benefits for your child taking part in this study, the researcher may learn more about (insert description).}

Compensation(if applicable)

{Describe any compensation or credit that participants may receive for taking part in the study. Include an explanation of alternatives to participation when participation is for classroom credit.}

Confidentiality

The results of this participation will be {select anonymous, or if identifiable information is to be collected, select confidential – but NOT BOTH. Describe how you will maintain the confidentiality of the subject, detailing how you will safeguard collected data to ensure anonymity or confidentiality as noted in Question 7 of the IRB Approval Request form.}

Use of Online Surveys(if applicable)

{Indicate whether IP addresses will or will not be collected. See instruction note under Question 5 of the IRB Approval Request form.}

Inclusion Criteria for Participation

{Include information in this section regarding the age of intended participants. See instruction note under Question 6 of the IRB Approval Request form.}

Parental Consent to Participate

I give my consent for my child, ______, to participate in the research project described above. I understand that this participation is voluntary and that I may withdraw my consent at any time without penalty. I also understand that my child may withdraw his/her assent at any time without penalty.

______

Signature of Parent or Authorized Representative, Date

______

Signature of Investigator, Date

______

PLEASE SIGN BOTH COPIES OF THIS FORM, KEEP ONE AND RETURN THE OTHER TO THE INVESTIGATOR

Research at Kennesaw State University that involves human participants is carried out under the oversight of an Institutional Review Board. Address questions or problems regarding these activities to the Institutional Review Board, Kennesaw State University, 585 Cobb Avenue, KH3403, Kennesaw, GA 30144-5591, (470) 578-2268.

______

Child Assent to Participate{consider using a separate assent document}

My name is {insert name of PI}. I am inviting you to be in a research study about {briefly describe the nature of the study in age appropriate language}. Your parent has given permission for you to be in this study, but you get to make the final choice. It is up to you whether you participate.

If you decide to be in the study, I will ask you to {describe what the child will be asked to do in simple language and include information regarding audio or videotaping that may occur. Describe benefits and risks to participation}.

You do not have to answer any question you do not want to answer or do anything that you do not want to do. Everything you say and do will be private, and your parents will not be told what you say or do while you are taking part in the study. When I tell other people what I learned in the study, I will not tell them your name or the name of anyone else who took part in the research study. {When relevant, inform child that you must inform authorities or health professionals as required.}

If anything in the study worries you or makes you uncomfortable, let me know and you can stop. No one will be upset with you if you change your mind and decide not to participate. You are free to ask questions at any time and you can talk to your parent any time you want. If you want to be in the study, sign or print your name on the line below:

______

Child’s Name and Signature, Date

Check which of the following applies (completed by person administering the assent.)

Child is capable of reading and understanding the assent form and has signed above as documentation of assent to take part in this study.

Child is not capable of reading the assent form, but the information was verbally explained to him/her. The child signed above as documentation of assent to take part in this study.

______

Signature of Person Obtaining Assent, Date

Page 1 of 3