ࡱ> OQN bjbjBGBG 4< -_ -_F F 8$Tx,*'"(&&&&&&&$),X&&&qqqR&q&qqr %T &`aVRa%&&0*'o%,m, &, &q&&*',F X : Informed Consent Form for a Research Study ĢTV Institutional Review Board Date: Research Project Title:  TITLE \* Upper \* MERGEFORMAT  Principal Investigator(s): Supervising Faculty (if applicable): Department: My name is [name] and I am currently a [title] at ĢTV (ĢTV) in the Department of [Department]. You are being invited to participate in the research study because you [reason the person matches the selection criteria or target population]. The research may give us knowledge that may benefit individuals or the society as a whole in the future. Details of the research are provided below. I, [Name of PI], the principal investigator, will be happy to answer further questions and concerns that you may have. Please contact me at [phone #] and/or email at [email address] if you have any questions before you decide to participate. Purpose of the Study The purpose of the study is Statements shall include the following: The purpose of the study The reason why the participant is being invited to take part A clear description of the study The number of participants anticipated by the researcher. Study Procedures You will be asked to Procedures should include the following: The specific protocols to be followed The duration of the subjects participation Description of data types that will be collected The research site(s) The frequency of the procedures The amount of time per procedure Risks or Discomfort of Participation Describe any reasonably foreseeable risks or discomfort that is expected to occur. Benefits of Participation Describe any benefits to the subject or others that may result from the research. Length of Participation The study will begin on [start date]. The [procedure, survey or questionnaire (choose one)] will take approximately [min/hr] of your time to complete. You may refuse to answer any questions or discontinue the [procedure, survey or questionnaire (choose one)] at any time without penalty or loss of benefits that you are otherwise entitled to. Compensation (choose one and delete the other) The compensation is to reimburse you for your time and /or any research-related inconveniences and discomforts. The compensation is due to you in the form of [monetary amount or other forms of compensation] at [state when participant should expect to be compensated]. You will be compensated for each [procedure, survey or questionnaire (choose one)] that you take part in. You will not receive any compensation if you choose not to participate in any part of the study or if you choose to withdraw prior to the first [procedure, survey or questionnaire (choose one)]. Or You will not be compensated for your participation in the research study. Confidentiality Your participation in the study is strictly confidential. The following information should be address: How subjects identity will be protected and secured through a coding system How and where the records will be stored/maintained When and by what means the records will be disposed of When and how the subjects will be notified if there is a breach in security When and how the researcher will contact the participants for permission to disclose their information if the study results in a publication and the identity of the participants are required to be disclosed How anonymity will be protected, if applicable Information about your involvement in this research study will not be released without your permission. You will be given a separate authorization form for the use or sharing of your information. It shall be signed by you. Otherwise, your participation will be kept private. Those who may have access to the study records include [list all persons, including faculty advisor]. Participant Rights Your participation is entirely voluntary. If you decide to participate in the study, you are free to withdraw at any time. You may choose not to participate. In either case, you will not lose any benefits to which you are otherwise entitled. You are not giving up any of your legal rights or releasing any individual or institution from liability for negligence. You will be given an opportunity to ask any questions or state any concerns that you may have about this study. Contact Information Please contact me, [Name of PI], the principal investigator, at [Phone] or email at [Email] with any questions or concerns about this study, your rights as a participant, any research-related injury or distress, or if you wish to withdraw from participating in the study. You may contact the ĢTV Institutional Review Board at (731) 989-6438 or email at HYPERLINK "mailto:IRB@ecok.edu"IRB@fhu.edu for additional information about your rights as a research participant. Consent Statement: I have read the explanation about the study described above and was given sufficient time to ask questions and review my options. By signing this form, I am indicating that I understand the benefits and risks associated with participating in this research and agree to participate. (Please return a signed copy of this form, and keep a copy for your records.) (Please check the box below that applies.) 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