University of Arkansas – Fort Smith
Title of Research Project
Introduction: You are invited to participate in a research project investigating ______________.
This study is conducted by Name and Title of Researcher. (If a student, state the name of the
faculty sponsor.) You were selected to participate in this research because _________________
(i.e. you are a class member of SURG 6403, a nursing student, etc). Please read this form in its
entirety and ask any question you may have before you agree to participate.
Purpose of the Study: State the purpose. State the number of possible participants.
Procedures: If you decide to participate, you will be asked to _______________. (Describe all
steps and procedures in a detailed fashion.)
The study will take approximately ____________ (how long, minutes, hours and how many
Risks and Benefits of Being in the Study: This study has (several or minimal) risks. First,
_________. Second, _______________. Explain the risks and likelihood of occurrence.
Describe any discomforts, inconveniences, psychological and/or physical. If there are risks, state
under what circumstances the researcher will terminate the study.
If there are risks from a physically invasive procedure or exercise component which may
have even the slightest risk of injury, include the following statement: In the event your
participation in this research study results in an injury, the researcher will assist you
(describe how you will assist the participant). Any medical care for research-related injuries
should be paid by you are your insurance. If you think you have suffered a research-
related injury, please let the researcher know immediately.
The benefits to participation are ___________________. If none, state “There are no direct
benefits to you for participating in this research.”
If you participate, you will receive ___________________________. Explain when and how
compensation will occur and under what conditions the participant will receive it. Delete this
section if not applicable.
Any information obtained in connection with this research study that can be identified with you
will be disclosed only with your permission. In any written reports or publications, group data
will used and no participant will be identified. (If you release any information to anyone for any
reason, you must state the persons or agencies to who the information will be furnished, the
nature of information released, and the purpose of disclosure).