Fillable IRB Informed Consent Parent-Minor Form 01.18.2019 INFORMED CONSENT (South Piedmont Community College)

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IRB Informed Consent Parent-Minor Form 01.18.2019 INFORMED CONSENT (South Piedmont Community College)

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IRB Informed Consent Parent-Minor Form
01.18.2019
Page 1 of 4
INFORMED CONSENT FOR PARTICIPATION IN RESEARCH ACTIVITIES
Whom to Contact about this study:
Principal Investigator:
Department:
Contact Information:
Invitation to be part of a research project:
Background Information:
Important Information:
Title of Project
Principal Investigator's Name
Department
Telephone number and/or email address
Your child has been invited to participate in a research study investigating (state what is being studied). This
study is being conducted by (xxxxxx, a/an (graduate/undergraduate) student(s) at South Piedmont Community
College under the supervision of xxxxxxx, a faculty member in the Department of xxxxxx). Your child was
selected as a possible participant in this research because (state how and why the subject was selected). Please
read this form and ask questions before you agree for your child to be in the study.
The purpose of this study is to (provide a general statement about what the study is designed to discover or
establish). Approximately (xx) people are expected to participate in this research.
*The purpose of this study is to [provide more information about study purposes]. If you choose to allow your
child to participate, your child will be asked to [do what, when, where, and how]. This will take approximately
[period of time/number of visits].
*Risks or discomforts from this study include [briefly describe].
*Benefits of this study include [briefly describe].
*There are alternative procedures or courses of treatment including [describe or remove if not applicable].
*Taking part in this research project is voluntary. Your child does not have to participate and your child can
stop at any time.
IRB Informed Consent Parent-Minor Form
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.18.2019
Page 2 of 4
Risks and Benefits of being in the study:
Procedures:
The study has several (or use the word minimal, if that is the case for your study) risks. First, ____________
second, _____________ (Risks must be explained, including the likelihood of the risk. Describe discomforts
and inconveniences the subjects may reasonably expect. If the subjects will be told of significant physical or
psychological risks to participation, they also must be told under what conditions the researcher will terminate
the study.)
The benefits to participation are (State benefits. If there are no direct benefits to the subjects, state "There are no
direct benefits to you for participating in this research."). (If applicable, describe appropriate alternative
procedures that might be to the subject's advantage, if any. Any standard treatment that is being withheld must
be disclosed.)
Additional Information:
Biospecimens may be used for commercial profit and individuals participating in this research project [will/will
not] share in this commercial profit.
Clinically-relevant results, including individual research results, [will/will not] be shared with individuals
participating in this research project [describe how].
If you decide to allow your child to participate, your child will be asked to [In a step-by-step fashion, describe
all steps and procedures you will follow, including their purposes, how long each step will take, and any
repetitions]. This study will take approximately (indicate the length of time the subjects will be participating in
the study during each interval) minutes/hours over (xx) sessions.
Confidentiality:
Voluntary nature of the study:
New Information:
If during the course of this research study the researcher(s) learns about new findings that might influence your
willingness to continue participating in the study, the researcher(s) will inform you of these findings. (This
section is optional. Consult your advisor to decide if it applies to your study).
Participation in this research study is voluntary. Your decision whether or not your child may participate will
not affect your future relations with (the name of any other cooperating institution or) SPCC in any way. If you
decide for your child to participate, you are free to withdraw from the study at any time without affecting these
relationships. (Explain here if monetary benefits will be adjusted if the subject withdraws early).
Any information obtained in connection with this research study that can identify your child will be disclosed
only with your permission; your child’s results will be kept confidential. In any written reports or publications,
no one will be identified or identifiable and only group data will be presented. (If it applies to your study,
include ways in which you will maintain confidentiality, e.g “No one in the daycare center will know your
child’s results.” If you release information to anyone for any reason, you must state the persons or agencies to
whom the information will be furnished, the nature of the information to be furnished, and the purpose of the
disclosure.)
Research results will be secured and only the research team will have access to this data during the project.
Data analysis will be completed by (specify the ending date of your research). All original reports and
identifying information that can be linked back to your child will be destroyed at the conclusion of this research
project. (If tape or video recordings are made, explain who will have access to them, if they will be presented to
others for educational purposes, and when they will be erased or destroyed.)
IRB Informed Consent Parent-Minor Form
01.18.2019
Page 4 of 4
Contacts and questions:
You may keep a copy of this form for your records.
Statement of Consent:
You are making a decision whether or not your child may participate. Your signature indicates that you have
read this information and your questions have been answered. Even after signing this form, please know that
you may withdraw from the study at any time.
__________________________________________________________________________________________
Child/Participant Name
__________________________________________________________________________________________
Parent/Guardian Name Date
__________________________________________________________________________________________
Signature of Parent/Guardian (Must be 18 years old to sign) Date
__________________________________________________________________________________________
Signature of Researcher Date
I consent for my child to participate in the study. (If you are video- or audio-taping your subjects, include a
statement such as "and I agree to allow my child to be videotaped.")
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IRB Informed Consent Parent-Minor Form 01.18.2019 INFORMED CONSENT (South Piedmont Community College)

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Completed 2 October 2020

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