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:
- 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.
- The possible psychological risks may be (please specify, in any). No physiological risks are anticipated.
- There are no discernible benefits to my child, although the results of this study will help expand our knowledge of (please specify).
- Although alternative procedures may be used, the present procedure is the most efficient, economical and least time consuming to my son/daughter/ guardian.
- 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.
- 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).
- 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.
- 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