[Please follow the instructions in red. You will need to remove the instructions as you go, including these instructions. The font of your completed document should be black and not red.]
[Insert the title of your study]
[Insert your name]
Liberty University
[Insert the name of your academic department/School of ___ ]
You are invited to be in a research study of [Insert a general statement about your study] . You were selected as a possible participant because [Insert the reason for participant selection] . I ask that you read this form and ask any questions you may have before agreeing to be in the study.
[Insert your name] , a [student/doctoral candidate/faculty member] in the [Insert the name of your academic department/school of ___] at Liberty University, is conducting this study.
Background Information: The purpose of this study is [Explain the research question you are hoping to answer/purpose of your research in lay language] .
Procedures: If you agree to be in this study, I would ask you to do the following things:
1.
[Insert your first task/procedure here. Be sure to include a time estimate, whether they will be recorded, and whether it is anonymous or confidential.
]
2.
[Insert your second task/procedure here (or delete this text). Be sure to include a time estimate, whether they will be recorded, and whether it is anonymous or confidential.
]
3.
[Insert your third task/procedure here (or delete this text). Be sure to include a time estimate, whether they will be recorded, and whether it is anonymous or confidential.
]
[ Note: 1. Anonymous means you won’t be able to tell to whom the data belongs. 2. Confidential means you’ll know what data belongs to whom, but you will not disclose identities. 3. Do not list reading/signing the consent form as a procedure.]
Risks and Benefits of being in the Study: The risks involved in this study [Describe any risks, including the likelihood of them occurring. If the risks are minimal, state “The risks involved in this study are minimal, no more than you would encounter in everyday life.”]
[ Note: Depending on the type of research you are conducting, you may become privy to information that triggers the mandatory reporting requirements for child abuse, child neglect, elder abuse, or intent to harm self or others. In these types of research, this must be disclosed as a risk to participants. If there are significant psychological risks to participation, the subject should be told under what conditions the researcher will terminate the study.]
[There are/there are not] benefits to participating in this study. [If applicable, insert a description of the benefits. You may also include benefits to society here.]

[ Note: If participants will not receive direct benefits, but there may be a benefit to society, state that fact here. Participants should not expect to receive a direct benefit simply from taking a survey or participating in an interview, however they may receive a direct benefit if they are taught a new skill, or if participation involves a teaching method, therapy technique, etc.]
[ Injury or Illness: (DELETE this section, including the title and paragraph below, unless this project involves more than minimal risk.)
Liberty University will not provide medical treatment or financial compensation if you are injured or become ill as a result of participating in this research project. This does not waive any of your legal rights nor release any claim you might have based on negligence.
]
Compensation: Participants [will/will not] be compensated for participating in this study. [If applicable, insert payment/reimbursement/incentive information here. If subjects receive class points or some other token, include that information here. Include when participants will be compensated, the conditions of payment, and whether or not monetary benefits will be pro-rated if a subject does not complete the study.]
Confidentiality: The records of this study will be kept private. In any sort of report I might publish, I will not include any information that will make it possible to identify a subject.
Research records will be stored securely and only the researcher will have access to the records.
[Include the following sentence if the data will not be anonymous and the possibility of sharing the data exists. If neither is the case, you may delete it. We may share the data we collect from you for use in future research studies or with other researchers; if we share the data that we collect about you, we will remove any information that could identify you before we share it.
]
[Include the following in this section:

A statement describing procedures taken to protect the privacy and confidentiality of the participant.

Describe how and where data will be stored plus how the data will be disposed of and any anticipated use of the data in the future.

Describe how recordings (if used) will be maintained, explain who will have access, if recordings will be used for educational purposes, and when they will be erased.

Discuss the limits of the confidentiality. For example, if focus groups are used, you cannot assure participants that other members of the group will maintain their confidentiality and privacy.

If your study is grant funded and subjects will be paid, the following statement should be included: “I understand that my name, social security number and address may be provided to the business office of Liberty University for the purpose of facilitating payment to me for participating in this study.”]
Voluntary Nature of the Study: Participation in this study is voluntary. Your decision whether or not to participate will not affect your current or future relations with Liberty University [Insert the names of any other cooperating institutions here.] . If you decide to participate, you are free to not answer any question or withdraw at any time without affecting those relationships.

[ How to Withdraw from the Study: [If participation is anonymous, the heading and below paragraph may be removed. If you are recording your participants, please include this heading and the below paragraph.]
If you choose to withdraw from the study, please contact the researcher at the email address/phone number included in the next paragraph. Should you choose to withdraw, data collected from you, apart from focus group data, will be destroyed immediately and will not be included in this study. Focus group data will not be destroyed, but your contributions to the focus group will not be included in the study if you choose to withdraw. [Revise the above as needed]]
Contacts and Questions: The researcher conducting this study is [Insert your name] . You may ask any questions you have now. If you have questions later, you are encouraged to contact
[him/her] at [Insert phone number/email] . You may also contact the researcher’s faculty advisor,
[Name] , at [Email] .
[ Note: If the researcher is a faculty member, the last sentence may be removed.]
If you have any questions or concerns regarding this study and would like to talk to someone other than the researcher [s] , you are encouraged to contact the Institutional Review Board,
1971 University Blvd, Carter 134, Lynchburg, VA 24515 or email at irb@liberty.edu
.
[ Note: Do not remove the above IRB information from this document]
Please notify the researcher if you would like a copy of this information to keep for your records.
Statement of Consent: I have read and understood the above information. I have asked questions and have received answers. I consent to participate in the study.
(NOTE: DO NOT AGREE TO PARTICIPATE UNLESS IRB APPROVAL INFORMATION
WITH CURRENT DATES HAS BEEN ADDED TO THIS DOCUMENT.)
The researcher has my permission to [audio-record/video-record/photograph] me as part of my participation in this study.
[ Note: If your study involves audio recording, video recording, or photographing participants, retain the above checkbox and permission statement, leave the appropriate method of recording listed, and remove the method(s) you will not utilize. If you will not be recording your participant(s), please remove the checkbox and permission statement.
]
______________________________________________________________________________
Signature Date
______________________________________________________________________________
Signature of Investigator Date