For EXAMPLE Purposes Only.
Researchers should modify and create forms that meet the needs of the research project.
Note: Assent forms should be written in language appropriate to the subject.
Department of
9201 University City Boulevard, Charlotte, NC 28223-0001
t/ XXX-XXX-XXXX f/ XXX-XXX-XXXX www.
Parental Informed Consent for
(Put the title of your project here)
Project Purpose:
Your child is invited to participate in a research study entitled. The purpose of this study is to (provide a brief
statement of the purpose of your study).
Investigator
This study is being conducted by …(your name, dept., and explanation of why you are conducting the
study such as ‘as part of the requirements for my masters degree, etc.) . The responsible faculty member
is…(your faculty advisor’s name, dept.) .
Description of Participation:
Your child will be asked to (provide brief description of what the participant should expect, such as:
complete course assignments, surveys, participate in class discussions, group activities, and online forums.
Some class sessions may be audio/video taped. (Provide brief info on how the data will be handled. Will
the data collected be anonymous or confidential? For example: Some of the data collected will be
anonymous and all data as well as you and your child’s participation will be kept confidential. The particular
steps to ensure this confidentiality include maintaining all collected data in a locked file cabinet which is only
accessible by the investigator and the immediate research staff. Data will be disposed of after six years. All
paper data will be shredded, and electronic data will be dismantled and, or rendered useless.
Length of Participation:
Your child’s participation in this project will begin sometime in MMYYYY while enrolled in the XYZ course.
The study will end MMYYY. If you decide to grant consent for your child to participate, your child will be one
of X=Total participants in this study.
Risks and Benefits of Participation:
(Provide example of risk if there is any, such as: There is no risk associated with this study. There may be
risks which are currently unforeseeable. (Provide an example of the benefit(s), such as: In an effort to
reduce teen risk behaviors, it is important to identify issues that students and parents’ would like to have
addressed in school programs. The benefits of participation in this study include:
 Improved science education course content
 Opportunity for improve attitudes about science and community building
Alternatives:
(IF there is an alternative provided, please explain, such as: Your child may participate in (name the
alternative) without being part of the study. This means that your child’s course work and verbal participation
(including surveys, interviews, and online forums) would not be used in the study, and not become part of the
research results.
Volunteer Statement:
Your child is a volunteer. The decision to participate in this study is completely up to you and your child. If you
and your child decide for your child to be in the study, your child may stop at any time. Your child will not be
treated any differently if you and your child decide not to participate, or if your child stops once your child has
started.
Confidentiality:
(Provide brief statement about how you will be handling the data you collect, such as: The data collected
by the Investigator will be kept confidential to the extent possible. The following steps will be taken to ensure
this confidentiality:
 Participants will not put their names on the survey
 No participant will ever be mentioned by name in the reported results
 Participants can end their participation at any time
 Participants can choose not to respond to any question
 Only the principal investigator and his research staff will have access to the raw data. All gathered data
will be stored in a locked cabinet and on a password protected computer.
Conflict of Interest:
The investigator has a financial interest in the company sponsoring this research. Describe financial interest.
OR, the investigator is receiving financial support to conduct this research. Describe financial support other
than study related expenses.
Fair Treatment and Respect:
UNC Charlotte wants to make sure that you are treated in a fair and respectful manner. Contact the University’s
Research Compliance Office (704-687-1871) if you have any questions about how you are treated as a study
participant. If you have any questions about the project, please contact your name and phone number, or your
faculty advisor and his/her phone number.
Participant Consent:
I have read the information in this consent form. I have had the chance to ask questions about this study, and
those questions have been answered to my satisfaction. I am at least 18 years of age, and I agree for my child to
participate in this research project. I understand that I will receive a copy of this form after it has been signed by
me and the Principal Investigator.
__________________________________________
Student Name (print)
__________________________________________
Parent Name (print
__________________________________________
_________________
Parent Signature
DATE
__________________________________________
Investigator Signature
_________________
DATE
This form was approved for use on Month, Day, Year for a period of one (1) year.