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.