Fillable Informed Consent for Participation in a Research Study (Samford University)

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Informed Consent for Participation in a Research Study (Samford University)

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Page%1%of%4%
Participant’s initials: __________
IRB approval number:
This form is valid for one year from approval date. Approval date:
Informed Consent for Participation in a Research Study
Principal%Investigator(s):%
%Study%Title:%
Name%of%participant:%___________________________________________________________________________%%%Age:%________%
1.
The%following%information%is%provided%to%inform%you%about%the%research%project/study%and%your%participation%in%it.%%Please read
this%form%carefully,%ask%any% questions%you% may%have% about% this%study% and% the%information%given%below,%and%be sure% you%receive
answers%to%your%questions%before%signing%this%consent%form%(a%copy%of%which%will%be%given%to%you).
2.
Purpose of this study:
The purpose of the study is
You are%being%asked%to%participate%in%a%research%study%because%
3.
The approximate duration of your participation in the study:
4.
Procedures to be followed for this study:
Page%2%of%4%
Participant’s initials: __________
5.
xperimental procedures involved in the study if any:
6.
escription of the discomforts inconveniences andor riss that can be reasonably expected as a result of your
participation in this study:
7.
ood effects or benefits that miht result from this study:
a. The%benefits%to%science%and%humankind%that%might%result%from%this%study:
b.
The%benefits%you might%get%from%being%in%this%study%(including%compensation,%if%any):
8.
lternative procedures or courses of treatments if any that miht be available:
9.
Privacy and Confidentiality:%%%%All%efforts,%within%reason,%will%be%made%to%keep%your%personal%information%in%your%research%record%
confidential.%%Your%information%may%be%shared%with%the%Samford%University%Institutional%Review%Board%or the%Office%for%Human%
Research%Protections%(Federal%Government).%%Your%information%will%only%be%used%for%monitoring purposes.
IRB approval number:
This form is valid for one year from approval date. Approval date:
Page%3%of%4%
Participant’s initials: __________
10.
n case of studyrelated inury:((%If%this%study%involves%more%than%minimal%risk%to%you,%the%following%compensation%and/or medical%
treatments%are%available%if%injury%occurs:
11.
Contact information: %%If%you%have%any%questions%about%this%research%study,%your%rights,%or%if%you experience a%study
related%injury,%please%contact:
at%(
or if principal researcher is a student,%Faculty%Adviso r%fo r%this%study:
at% %%%
If%you%have%additional%questions%or%concerns%that%are%not%answered%by%the%above%person(s),%feel%free%to%contact the%Samford%
University%Institutional%Review%Board%Chair:
Dr. Brad Bennett
205-726-4523
bbennet1@s
amford.edu%
12.
Your%participation%in%this%research%study%is%voluntary.%%You%are%free(to(withdraw%from%this%study%at%any%time without%penalty.%%
You are%also%free(to(withdraw%from%this%study%with%no%penalty.%%In%the%event%new%information%becomes available%that%may%affect%
the%risks%or%benefits%associated%with%this%research%study%or%your%willingness%for%you%to%participate in%it,%you%will%be%notified%so%
that%you%can%make%an%informed%decision%whether%or%not%to%continue%participation%in this%study.
Circumstances under which the Principal nvestiator may withdraw you from study participation:
IRB approval number:
This form is valid for one year from approval date. Approval date:
Page%4%of%4%
Participant’s initials: __________
STATEMENT(BY(PERSON(AGREEING TO PARTICIPATE(IN(THIS(STUDY:%
I%have%read%this%informed%consent%document%and%the%material%contained%in%it%has% been%explained%to%me%verbally.%%All%my%
questions%have%been%answered,%and%I%freely%and%voluntarily%choose%to%consent%to%participation%in%this%study.%%I% have%
received%a%copy%of%this%consent%form.%
___________________________________________________________________________________________%
%%Printed%name%of%Participant%
__________________________________________________________% __________________________%
%%Signature%of%Participant%
Date%
Consent(obtained(by:%
__________________________________________________________% __________________________________%
%%Printed%name% Title%
__________________________________________________________% __________________________%
%%Signature% Date%
IRB approval number:
This form is valid for one year from approval date. Approval date:
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Informed Consent for Participation in a Research Study (Samford University)

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Completed 26 August 2020

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