Template – C
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. Hello, my name is [identify yourself by name] from DePaul University.
2. We are asking you to permit your child 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 their child is being asked to participate. If the study involves a questionnaire, briefly describe the type of questions asked. State the time commitment for the child. (See IRB Policies and Procedures Handbook for some examples of different types of information included on Informed Consent Forms.)].
3. If you agree to allow your child to be in this study [describe what will take place from the individual’s point of view. If remuneration or other rewards will be offered during participation, these should be stated here and justified.].
4. [Describe the risks, if any, to the child and parent/guardian that may result from the child’s 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 child 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 your child to be in this study, your child does not have to participate. Remember, your child’s being in this study is entirely up to you and no one will be upset if you do not want your child to participate. You may even change your mind later and withdraw your agreement for your child’s participation without any consequences to you or your child. For children 8-17 years of age, please include "Even if you permit your child's participation in this study, your child may choose not to participate."
7. All information that your child provides in this research study will be kept strictly confidential and any report of this research will not identify your child 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 allow your child to be in this study. You will be offered a copy of this form after you have signed it.
10. End the consent form with the following two paragraphs:
Investigator’s signature ______________________ Date__________
Parent/guardian’s Consent: I have been satisfactorily informed of the above described procedure with its possible risks and benefits. I agree to allow my child ___________ (print child’s full name) to participate in this research study. If I have any questions regarding my child’s 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 child’s participation in this research study is voluntary and that I am free to stop my child’s participation at any time, without any consequences, even after signing this form. I have been offered a copy of this form.
Name of Parent/Guardian ____________ Date ___
Signature________________________