[Instructions: Choose Edit...Select All, or click and drag to select all text below, then
copy this text and paste it into your word processor consent document.]
University of California, San Diego
Consent to Act as a Research Subject
[Title of study]
Who is conducting the study, why you have been asked to participate, how you were
selected, and what is the approximate number of participants in the study?
[fill in name of PI and title, e.g., graduate student, PhD candidate, etc.] is conducting a
research study to find out more about [fill in research topic]. You have been asked to
participate in this study because you [fill in why the prospective volunteer was asked to
participate and how they were selected]. There will be approximately [fill in the total
number of expected participants to be enrolled] participants in this study.
Why is this study being done?
The purpose of this study is [fill in with a brief description of the research purpose(s)].
What will happen to you in this study and which procedures are standard of care and
which are experimental?
If you agree to be in this study, the following will happen to you:
[List study procedure(s) here, making clear if any procedure(s) or treatment(s) are
experimental.]
How much time will each study procedure take, what is your total time commitment,
and how long will the study last?
[Provide the duration/time associated with each study procedure and a separate statement
indicating the overall duration of the subject’s involvement in the study].
What risks are associated with this study?
Participation in this study may involve some added risks or discomforts. These include
the following:
1. A potential for the loss of confidentiality [In addition, insert a statement describing
the study procedure(s) that will be used to maintain confidentiality]. Research records
will be kept confidential to the extent allowed by law. Research records may be
reviewed by the UCSD Institutional Review Board and [fill in entities that may have
access to research records such as NIH, etc.].
2. [Is there a potential for boredom, fatigue or emotional distress? If so, please describe
these risks and study procedures that will be done to minimize risks.]
3. [Is there a potential for the person to experience risks related to the political, social or
economic context in which they live? If so, please describe these risks and study
procedures that will be done to minimize risks.]
(**Be very considerate of the subject)
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If it is reasonably foreseeable that the study will have access to or collection of
information that Federal, State, and/or local laws/regulations requires or may require to
be reported to other officials and the study includes investigator(s) who is/are a
“mandated reporter” of child or elder abuse, please use the following:]
Under California law, we must report information about known or reasonably suspected
incidents of abuse or neglect of a child, dependent adult or elder including physical,
sexual, emotional, and financial abuse or neglect. If any investigator has or is given such
information, he or she may be required to report such information to the appropriate
authorities.
[If the study includes investigator(s) who is/are not a “mandated reporter” of child or
elder abuse, please use the following:]
We may need to report information about known or reasonably suspected incidents of
abuse or neglect of a child, dependent adult or elder including physical, sexual,
emotional, and financial abuse or neglect. If any investigator has or is given such
information, he or she may report such information to the appropriate authorities.
Because this is a research study, there may also be some unknown risks that are currently
unforeseeable. You will be informed of any significant new findings.
What are the alternatives to participating in this study?
The alternatives to participation in this study are [In most cases, the alternative is simply
not to participate, but include procedures for special cases, such as how classroom
students may choose not to be subjects of a study organized by the professor].
What benefits can be reasonably expected?
There may or may not be any direct benefit to you from participating this study
[However, if there is no direct benefit to the subject from participation, this must be
clearly stated]. The investigator, however, may learn more about [insert research topic
here], and society may benefit from this knowledge.
Can you choose to not participate or withdraw from the study without penalty or loss of
benefits?
Participation in research is entirely voluntary. You may refuse to participate or withdraw
or refuse to answer specific questions in an interview or on a questionnaire at any time
without penalty or loss of benefits to which you are entitled. If you decide that you no
longer wish to continue in this study, you will be required to [fill in requirements for
orderly termination of study participation].
You will be told if any important new information is found during the course of this study
that may affect your wanting to continue.
Can you be withdrawn from the study without your consent?
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The PI may remove you from the study without your consent if the PI feels it is in your
best interest or the best interest of the study. You may also be withdrawn from the study
if you do not follow the instructions given you by the study personnel.
Will you be compensated for participating in this study?
In compensation for your time and travel, you will receive $ [fill in amount] for
participating in this research. [Stipulate how compensation is established. This amount
must be prorated. Be very specific. However, if no compensation will be given, it should
be stated.]
Are there any costs associated with participating in this study?
There will be no cost to you for participating in this study [However, if there are costs
associated to participation, these should be stated (i.e., parking costs)].
What if you are injured as a direct result of being in this study?
[If this study involves study procedures that could potentially cause injury including
physical and psychological such as EEG testing, fMRI, etc. please use:]
If you are injured as a direct result of participation in this research, the University of
California will provide any medical care you need to treat those injuries. The University
will not provide any other form of compensation to you if you are injured. You may call
the Human Research Protections Program Office at (858) 657-5100 for more information
about this, to inquire about your rights as a research subject or to report research-related
problems.
Who can you call if you have questions?
[fill in name of PI] and/or ________________ has explained this study to you and
answered your questions. If you have other questions or research-related problems, you
may reach [fill in name of PI] at [fill in telephone number of PI].
You may call the Human Research Protections Program Office at (858) 657-5100 to
inquire about your rights as a research subject or to report research-related problems.
Your Signature and Consent
You have received a copy of this consent document.
You agree to participate.
________________________________________________
Subject's signature
_______________
Date
**If oral consent or waiver of documented consent is requested, no signature line is
needed
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