You are invited to participate in a research study. The purpose of this study is to determine … (Explain).
- Methods to be used (give details).
- Data will be analyzed … (details of how data will be analyzed).
- The study will take place during (give expected dates).
- Depending on the results, data may be used in further analysis by research scientists.
(Describe the risks.)
This project will …. (state the intended benefit).
The information in the study records will be kept confidential. Data will be stored securely and will be made available only to persons conducting the study unless you specifically give permission in writing to do otherwise. No reference will be made in oral or written reports that could link you to the study. No identifiers (name, age, etc.) will be disclosed to anyone, and all information will be destroyed at the completion of the study.
If you have questions at any time about the study or the procedures, (or you experience adverse effects as a result of participating in this study,) you may contact …. (list Adult Sponsor/Qualified Scientist if one is involved, and the phone number/e-mail address for participants to call upon).
Your participation in this study is voluntary; you may decline to participate without penalty. If you decide to participate, you may withdraw from the study at any time without penalty.
I have read the above information, reviewed the questionnaire (if one is involved) and agree to participate in this study.
Participant's name (print) ____________________________________
Participant's signature _______________________________________ Date ______________
Parent/Guardian's name (print) _______________________________
Parent/Guardian's signature __________________________________ Date ______________