Genesis Health System Institutional Review Board (GHS-IRB)

Genesis Health System Institutional Review Board (GHS-IRB)

Template for Informed Consent When Using a Questionnaire/Survey

The following template is provided to assist in developing a cover letter that should accompany a research questionnaire or survey. The items that should be covered are in [bold and brackets] and embedded in the suggested letter. This template is recommended for questionnaires for which the subject's identify is keptanonymous. If the subject is to be identified, then provisions to maintain confidentiality must be included (where questionnaires will be kept, how subjects will/will not be identified, etc.).

Date ______

Dear ______:

We are writing to invite you to participate in a [research] study. The purpose of the study is to determine [Study Objective]______.

We are inviting you to be in this study because [Inclusion Criteria]______. Approximately [No. of participants]______participants will be invited to take part in this study.

If you agree to participate, we would like you to complete an online survey. This ____ question survey will take approximately ___ minutes to complete. The survey is anonymous and the results will not reflect individual responses. You are welcome to skip any questions that you prefer not to answer.

[Confidentiality Statement] We will keep the information you provide confidential, however federal regulatory agencies and the Genesis IRB may inspect and copy records pertaining to this research. If we write a report about this study we will do so in such a way that you cannot be identified.

The only potential risk to this study is the small chance that others may see the responses to your questionnaire and [Potential Risks]______.

[Costs] You will not have any costs for being in this research study.

[Reimbursement] You will not be paid for being in this research study.

[Voluntary Statement] Taking part in this research study is completely voluntary. If you decide not to be in the study, or if you stop participating at any time, you won't be penalized or lose any benefits for which you otherwise qualify.

If you have questions about the research study itself, please contact [PI Contact Information].

If you have questions about the rights of research subjects, please contact the [IRB Contact Information] Genesis Health System Institutional Review Board at (563) 421-7955 or .

Thank you very much for your consideration.Clicking the link below will indicate your willingness to participate in the study. If you do not wish to participate you may delete this e-mail.

[Insert survey link]

Sincerely,