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Institutional Review Board

Sample Forms: Minor Consent Form

CONSENT FORMS MUST BE ON NDNU LETTERHEAD

Agreement to Participate in Research

RESPONSIBLE INVESTIGATOR: Your name here

TITLE OF RESEARCH PROJECT: Your title here

Your son/daughter/guardian is invited to participate in a research study that is investigating (specify in general purpose of study).

II understand that:

  1. My son/daughter/guardian will be asked to read and answer a questionnaire in writing.  The questionnaire will take about (#) minutes to complete.  The questionnaire will be administered at my child’s school, outside of school hours, in an assigned classroom or at an after school center.
  2. The possible psychological risks may be (please specify, in any).  No physiological risks are anticipated.
  3. There are no discernible benefits to my child, 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 efficient, economical and least time consuming to my son/daughter/ guardian.
  5. The collective results of this study may be published, but any information from this study that can be identified with my son/daughter/guardian will remain confidential and anonymous.  All published results will be pooled. General results from the individuals participating in the study may be obtained by contacting (your 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.
  6. My consent is given voluntarily without being coerced.  My son/daughter/guardian may refuse to participate in this study or in any part of this study, and I may withdraw my consent at any time, without prejudice to my relation or my child’s relation with NDNU and (specify organization/institution).
  7. My son/daughter/guardian may decline to answer any question.  He/she may withdraw from the study at any time without prejudice to my child’s relationship with his/her school/center or future involvement with NDNU.
  8. I have received a copy of this consent form for my file.

HAVING READ THE INFORMATION PROVIDED ABOVE, I HAVE MADE A DECISION WHETHER OR NOT MY SON/DAUGHTER/GUARDIAN MAY PARTICIPATE.  MY SIGNATURE INDICATES THAT MY SON/DAUGHTER/GUARDIAN MAY PARTICIPATE AND IS WILLING TO PARTICIPATE.

_______________              __________________________             _______________________

Date                                       Print Parent’s/Guardian’s Name              Print Child’s Name

__________________________             _______________________

Parent’s/Guardian’s Signature                 Child’s Signature

_________________________             _______________________

Relation to Child                           Investigator's Signature