Institutional
Review
Board
Consent Form Template
2009
University of Arkansas – Fort Smith
Title of Research Project
Consent Form
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
sessions).
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.”
Compensation:
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.
Confidentiality:
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).
The results will be kept in a locked filed cabinet in _________ and only I (name anyone else with
access) will have access to the records. All data will be analyzed by (date). At that point all
original reports and identifying information will be destroyed. (This goes for tape or video
recordings also)
Participation: Your participation in this research study is voluntary. Your decision whether or
not to participate will not affect your relationship with University of Arkansas – Fort Smith in
any way. If you decide to participate, you are free to stop at any time without repercussion.
(Address how stopping will affect compensation here)
Changes in Progression of the Study: If during the course of this study, new findings occur
that might influence your willingness to continue participating in the study, we will inform you
of the findings. (This is optional section and may not apply to your study, omit if needed).
Contacts: If you have any questions, please contact me, ___________Name__ at
____________, or __Name__ at ____________. You may also contact Sydney Fulbright, IRB
Coordinator, at 788-7855. You may ask any questions now or if you have questions later, we will
be happy to answer them.
Statement of Consent:
You are making a decision whether or not to participate. Your signature indicates that you have
read this information and your questions have been answered. Even after signing this form, know
that you may withdraw from the study at any time.
I consent to participate in this study. (video- or audio-taping, add “and I agree to be
videotaped”.)
________________________________________ ____________________________________
Printed Name of Participant/Date Signature of Participant/Date
__________________________________________________________
Signature of Parent, Legal Guardian, or Witness/Date
(if applicable, otherwise delete this line)
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