C. Additional Sample Consent Form for Student Researchers Title of Study in Lay Language REQUIREMENTS: Identify yourself by name, affiliation, and your student status. Mention the name of the faculty supervisor. Also indicate for whom consent is being given, e.g., is consent being given by the actual participant, the parent of a minor who will be participating, etc. Clearly state that participating in the study is voluntary. SAMPLE WORDING: I authorize Jane Doe, M.A., a doctoral student under the supervision of Dr. ____ in clinical psychology at Pepperdine University, [name of school], to include me (my child, etc.) in the research project entitled “.....”. I understand my participation in this study is is strictly voluntary. State the purpose of the research project in lay language and how long the study will last. I have been asked to participate in a research project which is designed to study ...... The study will require ... meetings of approximately ... hours each. State why the participant has been asked to participate. I have been asked to participate in this study because ...... (e.g., I am a student, I experience panic attacks, my child is experiencing difficulties in school, etc.) In lay language, state the procedures, that is, what will the participant be asked to do. Be as specific as possible. I will be asked to ...... (e.g., complete intelligence testing, complete paper-pencil tests that will provide information about how I feel about myself, etc.) If audio or videotaping will be used in the study, this needs to be noted in the consent form along with the usages of the recorded material and how the material will be handled upon the completion of the study. I understand that I will be audiotaped (videotaped) if I decide to participate in this study. The tapes will be used for research purposes only. The tapes will be stored in a locked file cabinet and will be destroyed ..... (state when tapes will be destroyed). State the potential risks, regardless of how minor (e.g., fatigue, boredom, etc.), involved by participating in this study. Also describe the precautions that will be taken if participants experience discomfort. The potential risks of participating in this study are ..... In the event you do experience ..... (e.g., fatigue, etc.), ..... (e.g., a break will be provided, etc.). REQUIREMENTS: SAMPLE WORDING: Depending on the population and the nature of the study, the IRB may recommend that a list of referral sources be made available for use by the participant. With some populations and studies, it may be a good idea to have the list accompany the consent form, although on a separate page. This list must include low fee service providers. State the potential benefits to the participant. If none, so state. I understand there is no direct benefit from participation in this study, however, the benefit(s) to the profession (or humanity) may include...... or I understand the possible benefits from my participation in this study include ....... If a treatment is used in the study, identify the alternative treatments that exist and explain why the alternatives are not being used. I understand that treatments other than the one(s) used in this study are available, such as ...... The reason these other treatments are not being used is ...... Clearly state that participants are free to withdraw from the study at any time without penalty. Furthermore, the participant has the right to refuse to answer any question. Also state the investigator has the right to terminate the participant's study participation without regard for the participant's consent. I understand that I have the right to refuse to participate in, or to withdraw from, the study at any time without prejudice to ..... ( e.g., my current or future medical care, etc.). I also have the right to refuse to answer any question I choose not to answer. I also understand that there might be times that the investigator may find it necessary to end my study participation. Discuss the confidential treatment of data and how the data will be stored. I understand that no information gathered from my study participation will be released to others without my permission, unless such a disclosure is required by law. I understand that under California law, the privilege of confidentiality does not extend to information about the abuse of a child. If the investigator has or is given such information, she (or he) is to report it to the authorities. The obligation to report includes alleged or probable abuse as well as known abuse. REQUIREMENTS: SAMPLE WORDING: Furthermore, under California law, the investigator is obligated to report any evidence of physical abuse against elders or dependent adults, or if a person indicates she or he wishes to do serious harm to self, others, or property. (Preferred if children/adolescents are participants) or I understand that no information gathered from my study participation will be released to others without my permission, or as required by law. Under California law, an exception to the privilege of confidentiality includes but is not limited to the alleged or probable abuse of a child, physical abuse of an elder or a dependent adult, or if a person indicates she or he wishes to do serious harm to self, others, or property. The data being referred to are the raw data (e.g., questionnaires, tapes), not the database used for analysis. If participants are paid or provided some sort of incentive, specify the dollar amount if reimbursed in cash and terms of reimbursement. If not paid or provided an incentive, also indicate. If the findings of the study are published or presented to a professional audience, no personally identifying information will be released. The data gathered will be stored in locked file cabinets to which only the investigator (or research team members) will have access. (or The information gathered will be made available to other investigators with whom the investigator collaborates in future research. If such collaboration occurs, the data will be released without any personally identifying information so that I cannot be identified, and the use of the data will be supervised by the investigator.) The data will be maintained in a secure manner for 3 years (or 6 yrs. for studies that fall under HIPAA) at which time the data will be destroyed. (or The data may be kept for an indefinite period of time [or a minimum of 3 (6) years] for research purposes. After the completion of the study, the data will be destroyed.) I understand that I will receive $... for my study participation. If I choose to withdraw from the study, or I must end my study participation through no fault of mine, I will receive the full amount of reimbursement. Or REQUIREMENTS: SAMPLE WORDING: I understand that I will receive $... for my study participation. If I choose to withdraw from the study, I will be reimbursed $... for each hour of study participation I have completed. If the investigator chooses to end my study participation, I will receive the full amount of reimbursement. OR I understand I will receive no compensation, financial or otherwise, for participating in study. Identify the person responsible for the study procedures and where the person can be reached to answer questions. Also identify the person designated by the investigator's institutional I understand that if I have any questions regarding the study procedures, I can contact ..... (identify yourself) at ..... (address and phone number) to get answers to my questions. If I have further questions, I may contact Dr. _________________,(name of faculty supervisor and contact information). If I have further questions about my rights as a research participant, I may contact Dr. _________________, Chairperson of the (Seaver or GPS) Institutional Review Board, Pepperdine University, (insert contact information for Seaver or GPS IRB as appropriate). affiliation as responsible for the use of human participants. Include this statement at the end of the consent form. Provide signature and date lines for the participant. I understand to my satisfaction the information in the consent form regarding my participation in the research project. All of my questions have been answered to my satisfaction. I have received a copy of this informed consent form which I have read and understand. I hereby consent to participate in the research described above. ___________________________________ Participant's signature ___________ Date If the participant is a minor or unable to legally sign for other reasons, obtain the consent of the parent(s) or legal guardian/custodian. If both parents with legal custody are The participant is a minor (age _____), or is unable to sign because ________________ ____________________________________ ____________________________________ REQUIREMENTS: SAMPLE WORDING: required to consent to a minor’s participation, an additional signature line can be added. For minors 7-17 years, an assent form should be prepared. The assent form covers the material presented in the consent form in a more age-appropriate language.) ____________________________________ Parent/Guardian/Custodian signature _____________ Date Relationship to minor (Check): ___ Mother ___ Father ___ Legal Guardian Provide signature line for witness __________________________ Witness __________ Date I have explained and defined in detail the research procedure in which the subject has consented to participate. Having explained this and answered any questions, I am cosigning this form and accepting this person’s consent. Provide Signature and Date lines for the principal investigator ____________________________________ Principal Investigator __________ Date