CONSENT TO PARTICIPATE IN RESEARCH
Template – B
Enter the specific information about your study where ever there is a bracket ([ ]). (Use Depaul University Letterhead for all Participants)
[Insert title of the study using 15 point bold type.]

1. My name is [identify yourself by name] from DePaul University.

2. We are asking you to take part in a research study because we are trying to learn more about [outline what the study is about in non-technical language (assume an eighth-grade vocabulary). State the reason why the individual is being asked to participate. If the study involves a questionnaire, briefly describe the type of questions asked. State the time commitment for the individual. (See IRB Policies and Procedures Handbook for some examples of different types of information included on Informed Consent Forms.)].

3. If you agree to be in this study [describe what will take place from the individual’s point of view].

4. [Describe the risks, if any, to the individual that may result from participation in the research. State the actions taken to minimize risk and describe how confidentiality or anonymity will be maintained. (See IRB Policies and Procedures Handbook for some examples of how risks may be described and for statements that must be included for studies that present greater than minimal risk.)]

5. [Describe the benefits, if any, to the individual from participation in the research. If there are no benefits to the individual, indicate that and perhaps describe the general value of the study. (See IRB Policies and Procedures Handbook for some example statements.)]

6.  If you do not want to be in this study, you do not have to participate. Remember, being in this study is entirely up to you and no one will be upset if you do not want to participate. Even if you change your mind later and want to stop, you may withdraw your agreement to participate without any consequences.

7.  All information that you provide in this research study will be kept strictly confidential and any report of this research will not identify you personally in any way.

8. You can ask any questions that you have about the study. If you have a question later that you did not think of now, you can call me [insert your telephone number].

9. Signing your name at the bottom means that you agree to be in this study. You will be given a copy of this form after you have signed it.

10. (End the consent form with the following two paragraphs:)

Investigator’s Responsibility: I have fully explained to (participant's name) _________ the nature and the purpose of the above described research procedures and the risks and benefits involved in its performance. I have answered all (and will continue to answer all) questions to the best of my ability. I will inform the participant of any changes in the procedures or risks and benefits if they should occur during or after the course of this study. I have provided a copy of the consent form for the participant.

Investigator’s signature ______________________ Date__________

Participant’s Consent: I have been satisfactorily informed of the above described procedure with its possible risks and benefits. I agree to participate in this research study. If I have any questions regarding my rights as a participant in this research study, I may request to speak to the Coordinator of the DePaul University Institutional Review Board for the Protection of Research Participants by calling (773) 325-2593. I understand that my participation in this research study is voluntary and that I am free to stop participating at any time, without any consequences, even after signing this form. I have been offered a copy of this form.

Name of Participant ____________ Date ___

Signature________________________

 DPU-IRB approval number __________