SAMPLE CONSENT FORMS

TEMPLATE C: STUDENT INVESTIGATOR AND ADULT SUBJECTS

University of NorthTexas Institutional Review Board

Informed Consent Form

Before agreeing to participate in this research study, it is important that you read and understand the following explanation of the purpose, benefits and risks of the study and how it will be conducted.

Title of Study: ______

Student Investigator: ______, University of North Texas (UNT) Department of ______. Supervising Investigator: ______.

Purpose of the Study:You are being asked to participate in a research study which involves (describe the project in language the subject can easily understand).

Study Procedures: You will be asked to (explain specifically what the subjects will be asked to do) that will take about (specify thetotaltime commitment) of your time.

Foreseeable Risks: The potential risks involved in this study are (include any foreseeable risks or discomforts which the subject may experience or state that “No foreseeable risks are involved in this study.”).

Benefits to the Subjects or Others: We expect the project to benefit you by (include any foreseeable benefits to the subjects or state that “This study is not expected to be of any direct benefit to you, but we hope to learn more about ____” to explain how the study may benefit others or may contribute to your field of study. Use “may” or “is expected to” because IRB studies cannot guarantee results).

Compensation for Participants: None ORYou will receive (describe any payment or other compensation) as compensation for your participation (include the timing for payment and any conditions for receipt of such compensation, i.e. is payment conditioned upon on completing all tasks requested or is there partial payment for completing some of the tasks. If extra credit is offered for a course, an alternative non-research activity with equivalent time and effort must be offered. If extra credit will be offered to some groups of students but not offered to others, submit a separate informed consent notice for each situation.).

Procedures for Maintaining Confidentiality of Research Records: (Describe the methods you will take to protect your subjects' confidentiality or anonymity,such as maintaining any identifying information and coded survey results in separate locations.) The confidentiality of your individual information will be maintained in any publications or presentations regarding this study.

Questions about the Study: If you have any questions about the study, you may contact (insert name of Student Investigator) at (insert contact information)or (insert name of Supervising Investigator)at (insert contact information).

Review for the Protection of Participants:This research study has been reviewed and approved by the UNT Institutional Review Board (IRB). The UNT IRB can be contacted at (940) 565-4643 with any questions regarding the rights of research subjects.

Research Participants’ Rights:

Your signature below indicates that you have read or have had read to you all of the above and that you confirm all of the following:

  • (Insert name of Student Investigator) has explained the study to you and answered all of your questions. You have been told the possible benefits and the potential risks and/or discomforts of the study.
  • You understand that you do not have to take part in this study, and your refusal to participate or your decision to withdraw will involve no penalty or loss of rights or benefits. The study personnel may choose to stop your participation at any time.
  • (If recruiting students as participants, insert the following statement here:) Your decision whether to participate or to withdraw from the study will have no effect on your grade or standing in this course.
  • You understand why the study is being conducted and how it will be performed.
  • You understand your rights as a research participant and you voluntarily consent to participate in this study.
  • You have been told you will receive a copy of this form.

______Printed Name of Participant

______Signature of Participant Date

For the Student Investigator or Designee:

I certify that I have reviewed the contents of this form with the subject signing above. I have explained the possible benefits and the potential risks and/or discomforts of the study. It is my opinion that the participant understood the explanation.

______Signature of Student Investigator Date

Office of Research Integrity & Compliance

University of North Texas

Last Updated: July 11, 2011

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