Institutional Review Board - University of West Florida

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Institutional Review Board
The University of West Florida
Recorded Media Addendum to Informed Consent
To the Investigator:
 Prepare this document by completing the required fields and inserting the
information needed.
 Delete the instructions in red.
 Use this document in addition to the informed consent form when using recorded
media in your research.
For use with general informed consent documents for studies that involve audio,
video, photographic, or any other recording (hereafter referred to as recording) of
research subjects.
Project Title: Project Title
Date: Date
Investigator: Investigator
Email Address Email address
Phone Phone
Description and Purpose of Recording:
Example: The researchers would also like to take photographs or make video or audio
recordings (or insert appropriate recorded media) of you (insert activity) performing in
order to (insert purpose) illustrate the research in teaching, presentations, and/or or
publications.
Confidentiality:
(All consent material should always advise subjects how anonymity or confidentiality
will be maintained. This confidentiality statement should address how the recordings will
be stored to maintain confidentiality. This confidentiality statement should describe how
long the recordings will be stored and what will happen to the recordings at the
completion of the study.)
Voluntary Consent:
By signing below, you are granting to the researchers the right to use your likeness,
image, appearance, and performance – whether recorded on or transferred to videotape,
film, slides, photographs, or other media – for preserving, presenting or publishing this
research. No use of recorded media will be made other than for the reasons stated herein.
Your participation is voluntary and your refusal to participate will involve no penalty or
loss of benefits to which you are otherwise entitled.
You may discontinue participation and withdraw this consent at any time without penalty
or loss of benefits to which you are otherwise entitled.
If you have any questions, please contact:
(include the contact information for the investigators)
University of West Florida Institutional Review Board
11000 University Parkway, Building 11
Pensacola, FL 32514
(850) 857-6378
[email protected]
Subject's Printed Name & Signature
Date
Parent / Legally Authorized Representative’s Printed Name &
Signature (If applicable)
Date
Investigator’s Printed Name & Signature
Date
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