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Institutional Review Board

Sample Forms: Adult Consent Form

CONSENT FORMS MUST BE ON NDNU LETTERHEAD

Agreement to Participate in Research

RESPONSIBLE INVESTIGATOR: your name

TITLE OF RESEARCH PROJECT: your title here

I have been asked to participate in a survey-based research study that is investigating (specify general purpose).  The results of this study should further our understanding of (__________________).

I understand that:

  1. I will be asked to take a survey at home that should take approximately (specify time commitment, e.g., twenty (20) minutes) to complete.
  2. The possible psychological risks may be some discomfort based on reaction to the survey questions.  Should any feelings be elicited based on my or my child’s participation in this study, I may contact (insert information for free services) No physiological risks are anticipated.
  3. There are no discernible benefits to me personally, although the results of this study will help expand our knowledge of (please specify).
  4. Although alternative procedures may be used, the present procedure is the most advantageous and economical.
  5. The results of this study may be published, but any information from this study that can be identified with me will remain confidential and the data will be pooled to maintain anonymity.
  6. Any questions about my participation in this study will be answered by (researcher name and contact info).  Any questions or concerns about this study should be addressed to (supervisor name and contact info). Complaints or concerns about this study may be addressed to Dr. Laury Rappaport, (Chair, Institutional Review Board, NDNU) at (650) 508-3674.
  7. My consent is given voluntarily without being coerced.  I may refuse to participate in this study or in any part of this study, and I may withdraw at any time, without prejudice to my relation with (name of school or center) or with any future contact with NDNU.
  8. I have received a copy of this consent form for my record.

I HAVE MADE A DECISION WHETHER OR NOT TO PARTICIPATE.  MY SIGNATURE INDICATES THAT I HAVE READ THE INFORMATION PROVIDED AND THAT I HAVE DECIDED TO PARTICIPATE.

______________________________                        ______________________________

Print  Participant’s Name                                        Participant’s Signature

______________________________                        ______________________________

Date                                                                            Investigator’s Signature