Consent Form
[Insert Title of Study]

You are invited to be in a research study of [Insert general statement about study]. You were selected as a possible participant because [Explain how subject was identified]. We ask that you read this form and ask any questions you may have before agreeing to be in the study.

This study is being conducted by: [Name of Principle Investigator, department (indicate College affiliation)]

Background Information

The purpose of this study is: [Explain research question and purpose in lay language]

Procedures:

If you agree to be in this study, we would ask you to do the following things:
[Explain tasks and procedures: subjects should be told about video or audio taping, assignment to study groups, length of time for participation, frequency of procedures, etc.]

Risks and Benefits of being in the Study

The study has several risks: First, [Risk]; Second, [Risk] (Risk must be explained, including the likelihood of the risk)

(If there are significant psychological risks to participation, the subject should be told under what conditions the researcher will terminate the study)

The benefits to participation are: [Benefit(s)] (If no benefits, state that fact here.)

Measures to be taken to minimize risks and discomforts:  Please describe in lay terms any measures taken to minimize risk and discomfort of the subject during his/her participation in the research study

Compensation:

You will receive payment: [Include payment or reimbursement information here.] (If subjects receive class points or some other token, include that information here. Explain when disbursement will occur and conditions of payment. For example, if monetary benefits will be prorated due to early withdraw.)

Confidentiality:

The records of this study will be kept private. In any sort of report we might publish, we will not include any information that will make it possible to identify a subject. Research records will be stored securely and only researchers will have access to the records. (If tape recordings or videotapes are made, explain who will have access, if they will be used for education purposes, and when they will be erased.)

All information obtained in this study is strictly confidential unless disclosure is required by law.  In addition, the IRB, the sponsor of the study, and College or government officials responsible for monitoring this study may inspect these records.

Voluntary Nature of the Study:

Participation in this study is voluntary. Your decision whether or not to participate will not affect your current or future relations with SUNY Delhi [or with other cooperating institutions, insert names here]. If you decide to participate, you are free to not answer any question or withdraw at any time without affecting those relationships. 

Contacts and Questions:

The researchers conducting this study are: [Name of researcher] and [Name of researcher]. You may ask any questions you have now. If you have questions later, you are encouraged to contact them at [Location], [Phone number], [E-mail address]. (If the researcher is a student, include advisor’s name, telephone number and e-mail address here.)

If you have any questions or concerns regarding this study and would like to talk to someone other than the researcher(s), you are encouraged to contact the IRB chair, Katherine Quartuccio at quartuke@delhi.edu  or (607) 746.4812. 

You will be given a copy of this information to keep for your records.

Statement of Consent:

I have read the above information. I have asked questions and have received answers. I consent to participate in the study.

Signature:____________________________________________	Date: __________________

Signature of Investigator:_________________________________	Date: __________________