Name of Study
IRB Approved
Page 1 of 2
EDINBORO UNIVERSITY OF PENNSYLVANIA
Edinboro, Pennsylvania
CONSENT TO PARTICIPATE IN A RESEARCH STUDY
Title of Study: Use a general title of the study.
Principal Investigator:
Co-investigator(s):
Introduction
This section makes it clear that a study is to be conducted and the individual is being
“asked” to participate. It can also indicate why the individual was chosen.
You are being asked by _____ to be in a research study. You should understand that this
study involves research. This consent describes your role as a participant in the study.
Purpose of The Study
Include purpose(s) (either short or long term) of the research AND the expected duration
of participation including any follow-up.
What Will Happen During the Study?
Outline the procedures, in a time-sequence fashion. If there are two groups with different
treatments, outline how an individual is selected for each group. Indicate if any
procedures are experimental. This should be VERY clear and in terms that someone who
is not familiar with the study area would understand. Think - What information would I
want to know about a study before agreeing to participate?
What Are the Possible Risks or Discomforts?
Explain the most serious and common risks that could happen as a consequence of
participating in the study (include physical, emotional, psychological, social, financial,
and spiritual effects).
What Are the Possible Benefits of Being in This Study?
Include benefits to the participant OR to society as a whole.
Are Other Treatments Available? (Include only if appropriate - if not delete)
You may choose not to have any treatment.
How Will the Data Collected Be Kept Confidential?
You should know that your name will be kept as confidential as possible, within local,
state and federal laws. Records that identify you and this signed consent form may be
looked at by the Edinboro University Institutional Review Board (IRB). The results of
this study may be shared in aggregate form at a meeting or in a journal, but your name or
individual results/score(s) will not be revealed. (Explain how information from the study
will be kept, if pseudonyms will be used how that will work, and if ultimately the data
will be destroyed).
Name of Study
IRB Approved
Page 2 of 2
What Happens If I Have More Questions?
Your questions about a research-related injury or the research study will be answered
by_____ at (814) _______. If you have a question about your rights as a research
participant that you need to discuss with someone, you can call the Edinboro University
Institutional Review Board at (814) 732-2856 or at irb-chair@edinboro.edu.
What Will Happen If You Decide Not To Be in the Study?
Your participation is strictly voluntary. Also, you may decide to quit at any time without
any penalty, retribution, or repercussion.
SUBJECT’S STATEMENT
I had a chance to ask questions about the study. These questions were answered to my
satisfaction.
I realize that being part of this study is my choice. I am at least 18 years of age. I have read the
consent form. I was given a copy of this consent form for my own records.
SUBJECT’S SIGNATURE
Rev. 09/04/14
DATE