Ana G. Méndez University System - Sistema Universitario Ana G

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ANA G. MÉNDEZ UNIVERSITY SYSTEM
(Institution)
(Campus)
(School/Department)
Parent Permission Form
[Title of the Study/Research]
Description of the Research and Your Child’s Part in It
[Insert the Principal Investigator’s name here], Principal Investigator and [Insert CO-PI and/or
MENTOR’s name], CO-PI and/or MENTOR from the Ana G. Méndez University System
(AGMUS) are inviting your child to take part in a research study. The purpose of this research is
[explain the purpose of the study in easily understood language].
Your child’s part in this study will be to [describe the procedures that will be followed in easily
understood language].
It will take your child about [provide an estimate of the expected duration of the child’s participation
in the study] to take part in this study.
Risks and Discomforts
[We do not know of any risks or discomforts to your child in this research study] OR [There are
certain risks or discomforts that we might expect your child to go through if they take part in this
research]. They include [describe any reasonably foreseeable risks or discomforts to the child. You may
also describe the measures you will take to minimize these risks and discomforts].
Possible Benefits
[Describe any benefits to the child and to others that may reasonably be expected from the research] OR
(We do not know of any way your child would benefit directly from taking part in this study]. [If
appropriate, add] However, this research may help us to understand [limit to a brief
statement].[Indicate if another person or an institution will obtain benefit of this study and
describe the what will the benefit be].
AGMUS_IRB_Parent Consent
English Version
Approved through 7/2013
Revised 7/2012
Page 1 of 3
Incentives
[Describe any incentives that will be offered to encourage participation] (e.g., money, gifts, course
credit.) [If you are not offering incentives, you may leave out this section.]
Protection of Privacy and Confidentiality
[Describe the extent to which confidentiality of records identifying the participant will be protected.] [If
appropriate, precede this description with] we will do everything we can to protect your child’s
privacy and confidentiality; and we will not tell anybody outside of the research team that your
child was in this study or what information we collected about him in particular. However, the
data will be stored for a period of 5 years [Indicate where] and under the custody of the Principal
Investigator. Once the study has concluded it’s five (5) year period all data will be destroyed
[explain who data will be destroyed]. Your child’s data will be protected and maintained
confidential as dictated by the Privacy and Confidentiality ACT (HIPAA). This authorization
will be valid until the study/research has been completed, or until your child or you decide not to
continue.
Deciding whether your child should participate in the study
Your child does not have to be in this research study. You do not have to let your child be in the
study. You may tell us at any time during the study that you do not want your child to continue
in the study. Your child will not be punished in any way if you decide not to let your child be in
the study or if you stop your child from continuing in the study. [If data will be collected in
schools, include the following statement:] Your child’s grades will not be affected by any
decision you make about this study.
We will also ask your child if he wants to take part in this study. Your child will be able to refuse
to take part or to quit being in the study at any time.
Contact Information
If you have any questions or concerns about this study or if any problems arise, please contact,
[insert the Principal Investigator’s name here], [insert e-mail address] at AGMUS at [xxx-xxxxxxx]. If you have any questions or concerns about your child’s rights in this research study,
please contact the AGMUS Office of Research Compliance (ORC) at 787-751-3120 or
[email protected]
AGMUS_IRB_Parent Consent
English Version
Approved through 7/2013
Revised 7/2012
Page 2 of 3
Consent
I have read this document and have been allowed to ask any questions I might have. I give
my permission for my child to be in this study.
______________________
Parent’s Name
________________________
Parent’s signature
________________________ _________________________
Legal Representative Name
Representative’s signature
________________
mo/day/yr
________________
mo/day/yr
________________________
Child’s Name
________________________ __________________________
Investigator’s Name
Investigator’s Signature
________________
mo/day/yr
NOTE:
It is our responsibility to give you a copy of this form. Please select your comments to this
statement.
I certify that a copy of this document was given to me
I certify that a copy of this document was given to me, but I do not want a copy of
this document.
AGMUS_IRB_Parent Consent
English Version
Approved through 7/2013
Revised 7/2012
Page 3 of 3
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