ࡱ> ?A>K bjbj*S*S .,H94iH94i  $'))))))$PMMb''jP^x0?L<MML X b: Template for Informed Consent Form, Parent/Legal Guardian Permission [with Child Assent (age 12 or older)] Introduction The Department of at СӰԺ supports the practice of protection for human research participants. The following information is provided for you to decide whether you wish for your child to participate in the present study. You may refuse to sign this form and not allow your child to participate in this study. You should be aware that even if you agree to allow your child to participate, you and/or your child are free to withdraw at any time. Refusal to allow your child to participate or a decision to withdraw your child from the study will not result in a penalty of any kind for you or your child. Purpose of the Study Provide a brief description of the purpose of the study. Procedures Provide a brief description of the procedures that will be followed, and the anticipated time commitment for the participants (i.e., tell parents/guardians what the child will be doing. For example, In this study, participants will provide their reactions to a list of words presented to them on a computer screen and complete a brief demographics questionnaire. It is anticipated that this will take no more than 20 minutes of participants time). Risks and Benefits Insert a description of any burdens, inconveniences, pain, discomforts, and risks associated with participation in the study. If no risks are anticipated, this should be stated explicitly. Insert a description of the potential benefits, if any, to the research participant. Specify if these are direct benefits to the participant, or indirect benefits (e.g., to society). If there are no anticipated benefits, this should be explicitly stated. Payment to Participants If participants will be paid, insert a statement regarding how much and on what schedule, and include the following statement: Because your child is being paid, the researchers may ask for your childs social security number in order to comply with federal and state tax and accounting regulations. If participants will be given the opportunity to enter a drawing (e.g., for a gift card), state that here. If there is the possibility that participants will be awarded extra credit, state that here. Confidentiality Statement For this study, the researchers will collect information about your child. This information will be obtained from the study activities that are listed in the Procedures section of this Consent Form. In addition, information will be obtained from [insert description, e.g., a health questionnaire that you complete; the Registrars Office]. Your childs name will not be associated in any way with the information collected about your child or with the research findings from this study. The researcher(s) will use a study number, initials, or a pseudonym instead of your childs name. If it is necessary to connect participants names or other identifying information with their responses, state that here and explain how confidentiality will be maintained, identifiers eventually removed, etc., as applicable. The information collected about your child will be used by [list anyone who will have access to the data, including the student research director, co-researchers, faculty advisor. List any persons or groups external to the College with whom the researchers may disclose the information, and include a statement about the purpose of the disclosure]. Again, your childs name will not be associated with the information disclosed to these individuals. Participant Certification I have read this Consent Form. I have had the opportunity to ask, and I have received answers to, any questions I had regarding the study and the use and disclosure of information about my child for the study. I understand that if I have any additional questions about my childs participation in this study, I may contact the researchers listed at the end of this form. I agree to allow my child to take part in this study as a research participant. I further agree to the uses and disclosures of my childs information as described above. If you want a copy of this consent for your records, contact the Principal Investigator with the contact information provided below. Your signature documents your permission for the named child to take part in this research. Your childs signature documents his/her assent to participate (applies to children age 12 or older). Remove child assent for children under the age of 12. ______________________________________________________ __________________ Printed name of child/student Date ______________________________________________________ Signature of child/student ______________________________________________________ Printed name of parent [ ] or individual legally authorized [ ] giving permission for the child to participate ______________________________________________________ __________________ Signature of parent [ ] or individual legally authorized [ ] Date giving permission for the child to participate Researcher Contact Information John Doe Dr. Jane Doe Student Research Director Principal Investigator BC email address Department Campus address Campus phone number BC email address "$*19EFHWijklxyz5 D J   & S g 6 7 8 B C D       ѽؽؽ ho6] h~$6]hohyK5 h~$>* h~$5\h~$hSrj5CJ\ho5CJ\hyK55CJ\h~$5CJ\Hklyz 7 8 C D     ,-$a$q| *6PT@JUZ_`b<ABDIJ`ghtu| +,-PWi   {|hyK5h~$6] hyK56] h~$5\hyK5hyK56]hyK5hoh~$ h~$6]P  ~)*hjL{|JKLkgdSrjgdn !#~()*_ RTXrs^cghijKLRS]z{|hSrjhSrj6]aJhSrj6]aJ hSrjaJhSrjhSrjaJ hnaJh"_h"_aJhSrjh2Jwh~$L!",IJKLjkl hyK5h~$ h~$5\h2h"_hnaJhSrjhSrjCJOJQJ^JhSrjhSrjaJkl,1h/ =!"#$% x666666666vvvvvvvvv666666>666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List DB D n Body Text x7$8$ CJ]^J@/@ nBody Text Char ]^JaJL/L n Instructions56B*CJOJQJphPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y ,k8@0(  B S  ?-4? O ads33333319EFWjjKK19EFWjjKK ~$yK5}jSrjn2Jwo2"_@@UnknownG.[x Times New Roman5Symbol3. .[x Arial7..{$ Calibri3.[x TimesC.,.{$ Calibri LightA$BCambria Math"hJkJk& && &!20KQ@P  $P}j2!xxARW6 "Template for Informed Consent FormTim Henningsen Amy Posey Oh+'0 (4 T ` lx$Template for Informed Consent FormTim Henningsen Normal.dotm Amy Posey2Microsoft Office Word@V@<@<& ՜.+,0 hp  СӰԺ&  #Template for Informed Consent Form Title  !"#$%&'()*+,-/012345789:;<=@Root Entry FPUPBData 1TableWordDocument.,SummaryInformation(.DocumentSummaryInformation86CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q