ࡱ> _ $bjbj 4V9b9b8Yll8,},6(2"T `+++++++$.i1",^",ll7,!!!ll8+!+!!V(@(Peg3v^( +M,0},j(x2y2(("2)h"!_hhh",",[ hhh},2hhhhhhhhhB 2: Type in your Department Name Department Address Toledo, Ohio 43614 Phone # Fax # Instructions for completing this form are in RED TYPE. Please fill in requested the information in black type and then delete all red type instructions. Suggestion: Create an electronic folder for your study documents. Go to File in the upper left corner of this consent form template and Save as a new document to your study folder. If your Consent/Authorization form has an odd number of pages, please include an additional page labeled "NO TEXT THIS PAGE" as page 2 of the form before copying the entire form double-sided. Printing an even number of pages double-sided assures the Signature Section remains connected to the informed consent form details. ADULT RESEARCH SUBJECT - INFORMED CONSENT FORM (Title of Research Project) Key Information: {Be concise and focused in this section as you will elaborate on each key item later}. You are being invited to participate in a research study The purpose of the study is {briefly sum up the research purpose}. This research will take place {where}, will consist of {survey, interview, etc.}, and will take approximately {minutes/hours}. {If applicable, include alternative procedures, if not, delete} There are potential risks, including loss of confidentiality {briefly identify any other risks}. You may benefit from your participation in this research by {briefly identify any benefits to the participants}. Your participation in this research is voluntary Principal Investigator name, title, phone; Other Investigators name, title, phone; Purpose: You are invited to participate in the research project entitled which is being conducted at the University of Toledo under the direction of {PI, Others}.The purpose of this study is {type in purpose be brief but provide sufficient detail so that the subject may understand the scope of your work} Description of Procedures: This research study {or experiment} will take place in {state location and explain how much time (minutes/hours) and also length of participation, I session, 2 visits etc.} {Describe procedures, such as You will be asked to complete various questionnaires in which you will evaluate Be careful to avoid professional jargon. Strive for 8th grade readability.} {If applicable, state whether or not clinically relevant research results will be provided to participants and if so, under what conditions, when, how, etc.} If any form of video or audio recording is to be used, you will need to describe that here. Potential Risks: {Describe risks, such as potential discomfort, loss of confidentiality, etc. Describe any potential risks associated with de-identifying data for future research purposes (this refers to the new element of consent and is only applicable if you will include option one in the confidentiality section of this document, delete if you will include option two). Discuss the steps you will take to minimize any risks} Potential Benefits: The only direct benefit to you if you participate in this research may be that you will learn about how {psych, soc, experiments/surveys} are run and you may learn more about {subject of this research}. The field of {psych, soc, eng, etc.} may benefit from this research by {indicate any benefit to the field of study}. Others may benefit by learning about the results of this research. {If you will be giving extra credit, gift cards, etc., please include this here, identify the amount, and clearly identify the criteria for receiving such benefits for participation} {If appropriate, add a statement regarding alternative procedures and any benefits specific to these alternatives} {If your subjects include Psychology research pool students add If you decide not to participate you will not receive research credit. However, there are alternatives to participating in research (e.g. participating in other research studies or writing reviews of research articles} Confidentiality: Explain how signed consent documents and data will be stored and protected (i.e., locked file, password protected computer), who will have access to the data, and how long the data will be kept before it is destroyed (if applicable). Signed consent documents must be kept for at least three years after the project has been closed. You can discuss if data will be reported in aggregate, with pseudonyms, if you will quote participants, etc. Be sure to use language appropriate to your participants (i.e. an 8th grade reading level for the general population). If conducting a focus group, you cannot guarantee that others in the group will keep discussion confidential. You will ask everyone in the focus group to keep discussion confidential. If a coding strategy (i.e., a way to link a persons data over time) is being used to protect confidentiality, please explain. Remember, if you see the participant one-on-one (interview or focus group), participation is not anonymous. If you collect names, even if only for the consent document, participation is not anonymous. Use the term confidential and/or anonymous correctly. New element of consent: Include one of the two statements: 1. The information that is collected from your participation in this research may be used in future research studies without your consent, but only after your identifying information has been removed from the information. As a reminder, your agreement to participate in this research is voluntary. OR 2. The information that is collected from your participation in this research will not be used or distributed for future research. Voluntary Participation: Your refusal to participate in this study will involve no penalty or loss of benefits to which you are otherwise entitled and will not affect your relationship with ýĻƷ or any of your classes {add or substitute other entities as appropriate}. You may skip any questions that you may be uncomfortable answering. In addition, you may discontinue participation at any time without any penalty or loss of benefits. Contact Information: If you have any questions at any time before, during or after your participation {or experience any physical or psychological distress as a result of this research} you should contact a member of the research team (insert Principal Investigators name/Phone #; and name of second contact persons name/Phone #). If you have questions beyond those answered by the research team or your rights as a research subject or research-related injuries, the Chairperson of the SBE Institutional Review Board may be contacted through the Human Research Protection Program on the main campus at (419) 530-6167. CONSENT SECTION Please read carefully You are making a decision whether or not to participate in this research study. By {clicking next, completing the survey, marking yes, typing your name, etc.} you indicate that you have read the information provided above, you have had all your questions answered, and you have decided to take part in this research. You may take as much time as necessary to think it over. By participating in this research, you confirm that you are at least 18 years old.       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