Sample

Informed Consent form

Title of Study:_______________________________________________________________
______________________________________________________________________

You are being asked to take part in a research project by (principal investigator’s name) _________________________________. If you choose to take part, you will be
(describe what the individual will be asked to do in the project)  ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The possible risks to you while you participate in the project are (include all risks of physical and/or emotional harm.) ___________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________ 

You may stop at any time by using words or actions. If you stop, no one will ask you to continue at any time. There are no penalties for stopping. You should also understand that you do not have to take part in the project, even if your guardian has signed the consent form, you can choose at any time not to participate.  If you choose not to participate, it will have no effect on any present or future services that may be provided or purchased by the Department of Developmental Services in the Commonwealth of Massachusetts. 

Choosing to participate means you agree to let the researcher know  (describe all personal health information and identifying information that will be obtained from the participant) _____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________. 

The researcher will not let anyone else know of your private, personal information unless you agree. Any information that the researcher receives is treated as confidential. This means that no one except the researcher and (include all other persons who will have access to personal information.)_________________________ 
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The results from this study may be used for (describe all possible uses and dissemination of information obtained from the participants)__________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

A researcher (name)_______________________ will explain all of the procedures to you and answer any questions you may have. All goals and objectives of this research have been explained to you prior to your consent.

There will be someone available for you to contact if you have questions or if you feel uncomfortable as a result of your participation in this project. This person is (name, address, and phone number of a person who will be available to participants).
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(This person must be accessible at least on all days when research is conducted.)

Potential benefits that you may gain from participating are (include any monetary, property, or other tangible benefits, and any information that may be of benefit to the individual or others. The participants must be informed that they may obtain information about the findings after the project is completed.) You may obtain information about the findings of this project by contacting  (Include the name and address of the person who will be able to send information out to the participant.)_________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Confidentiality will be protected by (include description of the material to be obtained, e.g. written, audio/video/electronic, and the like, etc. and how it will be stored and later destroyed) _____________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you choose to sign this form it means you understood everything that the form says and that the researcher is here with you to explain what is on this form.

Signature of Participant:_____________________________    Date: ______________

Participant’s name (print)____________________________   

Phone Number to contact the participant:__________________________________ 

Signature of guardian(s) of the Participant (if Applicable):____________________  
Date:______________

I have fully explained the project to (participant)_________________________ and have answered all questions to the best of my ability.

Signature of Researcher:___________________________	Date:____________

I attest to the fact this individual understands and is able to give consent to participate in this study.

Signature of Witness (a person familiar with the participant and without interest in the research):_______________________________________