ࡱ> JLIc Q&bjbjzz 7@~]\~]\UZ Z 8Db$9)((((((($S+ .R((4(!!!(!(!!:&f'{5Hj ' ( )09)'R[.[.f'f'n[.'!((b9)[.Z > : Consent Form (If your study has multiple consent forms, give them each a name e.g. Parent Consent Form or Interview Consent Form) Purpose: You are invited to participate in a research study of (State what is being studied). I/we hope to learn (State what the study is designed to discover or establish). Participant Selection: You were selected as a possible participant in this study because (State why and how subject was selected; identify the population). Approximately X number of participants will be invited to join the study. Explanation of Procedures: If you decide to participate, you will (Describe the procedures to be followed, including their purposes, how long they will take, and their frequency. Provide 1-2 sample questions if a focus group or individual interview). Discomfort/Risks: (Describe any risks, discomforts and inconveniences that may be reasonably be expected. It cannot be assumed that no risks are expected). If no anticipated risks, include a statement such as There are no anticipated risks associated with participating in this study. However, if you feel uncomfortable with a question, you may skip it. If the study could potentially cause emotional or psychological distress, please include the following or insert other appropriate counseling options: If at any point you feel too distressed to continue the study, please inform the researcher and you may discontinue your participation without penalty. If the distress continues after you discontinue or finish participation, you may wish to contact the ڶ Counseling and Testing Center. They are located in Grace Wilkie Hall room 320, phone number (316)-978-3440, email Wanda.Holt@wichita.edu. Benefits: (Describe any benefits to subjects or society that may reasonably be expected). Confidentiality: Every effort will be made to keep your study-related information confidential. However, in order to make sure the study is done properly and safely there may be circumstances where this information must be released. By signing this form, you are giving the research team permission to share information about you with the following groups: Office for Human Research Protections or other federal, state, or international regulatory agencies; The ڶ Institutional Review Board; (If applicable, otherwise delete this bullet) The sponsor or agency supporting the study Sponsor Name The researchers may publish the results of the study. If they do, they will only discuss group results. Your name will not be used in any publication or presentation about the study. For focus groups, include that the focus group discussion is confidential to the group and to please not share what was discussed outside of the focus group. If audio-recording study activities, include where and how long the recording will be kept. Compensation or Treatment for Research Related Injury (ONLY include if applicable): If a research related injury is possible (Physical, Psychological, Social, Financial, or Otherwise) in research that is more than minimal risk and/or research that involves physical activity, you must include the following: ڶ does not provide medical treatment or other forms of reimbursement to persons injured as a result of or in connection with participation in research activities conducted by ڶ or its faculty, staff, or students. If you believe that you have been injured as a result of participating in the research covered by this consent form, you can contact the Office of Research and Technology Transfer, ڶ, Wichita, KS 67260-0007, telephone (316) 978-3285. Payment to Subjects (ONLY include if applicable): If payments will occur, include the amount of payment, the type of payment (check/gift card, etc.), the timing of payments, a statement that if subjects withdraw before the end of the study, they will be paid for the visits they have completed. Also include this paragraph: Study payments are taxable income. You will be asked to complete a W9 form which requires your name, address, and social security number in order for you to receive study payments. A Form 1099 will be sent to you and to the Internal Revenue Service if your payments are $600 or more in a calendar year. If students will be receiving class credit include a statement such as the following: For your participation you will receive X SONA credits. If you choose not to participate, your instructor will offer you an alternative activity for equivalent course credit. If using Greenphire ClinCards to pay participants, use the following language: You will receive $xx for each study visit. Include the following only if your study has multiple visits: If you complete all regularly scheduled visits, you may receive up to $xx. If your participation ends early, you will be paid only for the visits you completed. You will be given a ClinCard, which works like a debit card. After a study visit, payment will be added onto your card by computer. The money will be available immediately. You can use the ClinCard at an ATM or at a store. No one at ڶ will know where you spent the money. You will be given one card during the study. Some fees may apply, please read the insert that comes with the card for more information. If your card is lost or stolen, or if you are assessed fee on your card, please call Emily Geer at 316-978-5882. ڶ will be given your name, address, social security number, birthdate and the title of this study to allow them to set you up in the ClinCard system. Study payments are taxable income. A Form 1099 will be sent to you and the Internal Revenue Service if your payments are $600 or more in a calendar year. Include as applicable: We will also collect your cell phone number and/or email address to send you appointment reminders. Refusal/Withdrawal: Participation in this study is entirely voluntary. Your decision whether or not to participate will not affect your future relations with ڶ and/or (Include name of any other institution or agency involved). If you agree to participate in this study, you are free to withdraw from the study at any time without penalty. Contact: If you have any questions about this research, you can contact me at: (Name, Address, Phone and e-mail. NOTE: For student project, include contact information for student AND principal investigator. DO NOT INCLUDE STUDENTS PERSONAL ADDRESS only phone and ڶ email). If you have questions pertaining to your rights as a research subject, or about research-related injury, you can contact the Office of Research and Technology Transfer at ڶ, 1845 Fairmount Street, Wichita, KS 67260-0007, telephone (316) 978-3285. You are under no obligation to participate in this study. Your signature below indicates that: You have read (or someone has read to you) the information provided above, You are aware that this is a research study, You have had the opportunity to ask questions and have had them answered to your satisfaction, and You have voluntarily decided to participate. You are not giving up any legal rights by signing this form. You will be given a copy of this consent form to keep. ____________________________________________________ Printed Name of Subject ____________________________________________________ _______________________ Signature of Subject Date ____________________________________________________ Printed Name of Witness ____________________________________________________ ________________________ Witness Signature Date     Note: The Consent Form MUST be Placed on ڶ Departmental Letterhead   BGMRf/ 5 J L 񵥗}ooo_oQhK7hT26OJQJaJhh ?56OJQJaJhK7h ?6OJQJaJhK7hWOJQJaJhK7h ?OJQJaJhK7h ?5OJQJaJhK7h ?5>*OJQJaJh5>*OJQJaJh&z 6OJQJaJhh6OJQJaJh6OJQJaJh5OJQJaJhK7h5OJQJaJ 4 5     ~  z{;$ & F ^a$gd $1$7$8$H$a$gd$a$gd $ Ha$gd $ Ha$gd   5 7 _   ( * + } ~   ȺجȺج؃yoaTGh=h=OJQJaJhOJPJQJaJhh=h=6OJQJaJh=OJQJaJh ?OJQJaJhK7ht`OJQJaJhK7h66OJQJaJhK7h}$6OJQJaJhK7h ?6OJQJaJhK7h ?5OJQJaJhK7h ?5>*OJQJaJhK7h ?OJQJaJhK7hT26OJQJaJhK7hT2OJQJaJ!#{{'EFGqt:պykky^QGQh&z OJQJaJhK7h{vOJQJaJhK7haOJQJaJhJ9B*OJQJaJphhJ96B*OJQJaJph$hJ9hJ96B*OJQJaJph!hK7hFB*OJQJaJphhK7h*OJQJaJhK7hFOJQJaJhK7h ?6OJQJaJhK7h ?5OJQJaJhK7h ?5>*OJQJaJhK7h ?OJQJaJ:;<678HIVW_hnol #qrŵvh[N[AhK7h~OJQJaJhK7hBV"OJQJaJhK7h ?OJQJaJhK7h ?6OJQJaJhK7h ?5OJQJaJ!hK7h ?56>*OJQJaJhK7h ?5>*ϴK705>*ϴK725>*ϴ)Ұ6Oϴ)6Oϴ)6Oϴ)ϴ{ϴ;<78qrKLXY s t """I#$ & F^a$gd$a$gdr !%)4@reXeeeehK7h9OJQJaJhK7hOPOJQJaJhK7h:'OJQJaJhs6OJQJaJhK7h{vOJQJaJhK7hL6OJQJaJhK7hU]6OJQJaJhK7h{v6OJQJaJhh~5OJQJaJ!hK7ha56>*OJQJaJ!hK7h~56>*OJQJaJhK7h~5>*OJQJaJ @I\?gu=>ORi ´{n^PhK7h ?5OJQJaJhK7h ?5>*OJQJaJhK7h!6OJQJaJ hhhhOJQJhh6OJQJhOJQJh!6OJQJhh!6OJQJhh!66OJQJ]h ?OJQJaJhK7h~OJQJaJhK7h{vOJQJaJhK7hOPOJQJaJhK7hU]OJQJaJ t { ~ .!D!!!! 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