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1.
Purpose of the Study
A brief statement about why the study is being conducted
2.
Benefits of the Study
For you
For the subjects
For the scientific community and/or others
3.
What You Will Be Asked to Do
Tasks and procedures- include amount of time for each task and a total estimated time
Also, include exclusionary criteria, such as criteria to determine who is not suitable for participation in your study. For example, criteria that exclude participation in an exercise study may include cardiovascular disease risk factors. These factors could be identified by completion of a medical history form. In this case, the medical history form should be included in the HSR proposal appendix.
4.
Risks
Description of possible risks and compensatory follow-up, if any. Always include the possibility of minimal risk.
5.
Compensation for Injury
Standard clause if needed – Remove if not needed: If you suffer an injury that requires any treatment or hospitalization as a direct result of this study, the cost for such care will be charged to you. If you have insurance, you may bill your insurance company. You will be responsible to pay all costs not covered by your insurance. Ithaca College will not pay for any care, lost wages, or provide other financial compensation.
6.
If You Would Like More Information about the Study
What to do before or during or after the study and contact information for you and faculty advisor
7.
Withdraw from the Study
A statement that the subject is free to withdraw at any time without penalty, and to omit answers on questionnaires that they feel uncomfortable answering (if applicable) .
8.
How the Data will be Maintained in Confidence
A statement about the anonymity or confidentiality of the subjects' responses. (Be specific about the distinctions between anonymity and confidentiality; see operational definitions.)
Be sure to include that data will be kept for a minimum of 3 years. All electronic data must be stored on a password-protected computer in a faculty member’s office.
If subjects are being audiotaped and/or videotaped, a statement about where and how tapes will be stored, who will have access, and whether the tapes will be destroyed is required.
I have read the above and I understand its contents. I agree to participate in the study. I acknowledge that I am 18 years of age or older.
_____________________________________________________
Print or Type Name
_____________________________________________________ ____________________
Signature Date
I give my permission to be audiotaped (videotaped). (This sentence should only be used when appropriate.)
_____________________________________________________ ____________________
Signature Date

(If more than one page will be used, each page before the signature page should have a line provided at the bottom for subjects to initial.)