Contacts and Questions
The researcher conducting this study is: [PI’s name]. The researcher will be available to answer any questions about the study at: [phone number and email address]. If you have questions or concerns about your rights, you may contact the Regis Institutional Review Board Chair:
Dr. Margaret Oot-Hayes, PhD, RN
781-768-7163
margaret.oot-hayes@regiscollege.edu
Statement of Consent [Choose only one statement according to the type of consent form.]
[Adult Participant Informed Consent]
I have read this form (or have had it read to me). I have been encouraged to ask questions. I have received answers to my questions. I give my consent to be in this study. I have received (or will receive) a copy of this form. I understand the risks and discomforts associated with the above study and understand that I may quit the study at any time without penalty.
[Parent/Guardian Informed Consent for Participants Ages 17 and Younger]
I have read this form (or have had it read to me). I have been encouraged to ask questions. I have received answers to my questions. I give my consent for my child to be in this study. I have received (or will receive) a copy of this form. I understand the risks and discomforts associated with the above study and understand that my child may quit the study at any time without penalty.
Signature(s)/Date [Delete any that do not apply to your protocol.]
[Adult Participant Informed Consent]
Participant Printed Name: ___________________________________
Participant Signature: ___________________________________ Date: __________
[Parent/Guardian Informed Consent for Participants Ages 17 and Younger]
Study Participant Printed Name: ___________________________________
Parent/Guardian Printed Name: ___________________________________
Parent/Guardian Signature: ___________________________________ Date: __________
[Interpreter for Non-English-Speaking Participants]
Interpreter Printed Name: ___________________________________
Interpreter Signature: ___________________________________ Date: __________
[Participant’s Legal Representative]
Participant Printed Name: ___________________________________
Legal Representative Printed Name: ___________________________________
Legal Representative Signature: ________________________________ Date: __________
Witness Printed Name: ___________________________________
Witness Signature: ___________________________________
