Office of Sponsored Programs and Faculty Development

UW Oshkosh

Office of Sponsored Programs and Faculty Development

ExampleInformedConsentDocument

Youareinvitedtoparticipateinastudyof<StudyTopic>.This research studyisunderthedirectionof<ResearcherName>ofthe

<DepartmentNameorCourseName>attheUniversityofWisconsinOshkosh.Wehopetolearn<Explain Purpose/ KnowledgeYouHopetoGainfromResearch>.<Include criteria used/why population chosen as potential participantsofthisstudy>.

Ifyoudecidetoparticipate,wewillaskyouto<WhatWillBeRequiredofParticipants/Study Procedures>.Instructionsforthestudywillbedescribedinmoredetailorally.Eachdatacollectionsessionoftheexperimentwilllast<duration>. <Describe any benefits to participants or to others>. <Describe any reasonably foreseen risks or discomforts to participants>.

< Statement describing extent if any, to which confidentiality of records identifying subjects will be maintained; ie, Anyinformationinconnectionwiththisstudythatcanbeidentifiedwithyouwillremainconfidentialandwillbediscussedonlywithyourpermission.Ifanyreportsorpublicationsarecompleted,noonewillbeindentifiedoridentifiable.>

Theconsentprocessisdesignedtoprovideyouwithinformationregardingtheexperimentsoyouareabletoprovideaninformeddecisiononwhetherornottovoluntarily participate.YourdecisionwhetherornottoparticipatewillnotaffectyourfuturerelationswiththeUniversityofWisconsinOshkoshinanyway.Ifyoudecidetoparticipate,youarefreetodiscontinueparticipationatanytimewithoutaffectingsuchrelationship.Theinvestigators,IRBmembers, and theUniversityofWisconsinOshkoshareboundbyethicsandlawtoprotectparticipantsinresearchstudies.Participantsdonotwaiveanyrightsbysigningtheinformedconsentdocument.

Ifyouhaveanyquestionsabouttheresearchand/orresearchsubjectsʼrights,pleasecall or write<ResearcherName>at

<ResearcherPhoneNumber and email address>.Ifyouhaveanyquestionsorconcernsaboutthestudy or your rights as a research participant andwouldliketotalktosomeoneotherthantheresearcher,youmaycontact:

Chair,InstitutionalReviewBoardForProtectionofHumanParticipants

c/oOfficeofGrantsandFacultyDevelopmentUWOshkosh

Oshkosh,WI54901

(920)424-1415

Althoughthechairpersonmayaskyouforyourname,allcomplaintsarekeptinconfidence.Youwillbegivenacopyofthisformtokeep for your records.

Youaremakingadecisionwhetherornottoparticipate.Yoursignatureindicatesyouhavereadtheinformationprovidedaboveandhavedecidedtoparticipate.Youmaywithdrawatanytimewithoutprejudiceaftersigningthisformshouldyouchosetodiscontinueparticipationinthisstudy.

SIGNATUREDATE

SIGNATUREOFINVESTIGATORDATE

Lastupdated:12/20/2011Page1of1