SAMPLE INFORMED CONSENT FORM
SOUTHERN CONNECTICUT STATE UNIVERSITY:
School of Communication, Information and Library Science
Department of Information and Library Science
STANDARD ( [PARENT] [GUARDIAN] ) CONSENT FORM
Title of Study:
Investigator(s):
The following informed consent is required by Southern Connecticut State University for any person involved in a University-sponsored research study. This study has been approved by the University's Institutional Review Panel for Human Subjects.
I hereby give my consent ( for my [child] [ward] ) to be the subject of your research. You have given me:
- A. An explanation of the procedures to be followed in the project, including an identification of those that are experimental.
- B. Answers to inquiries I have made.
I understand that:
My ( [child's] [ward's] ) participation is voluntary, and ( I ( he/she ) ) may withdraw ( my ( his/her ) ) consent and discontinue participation in the project at any time. ( My ( His/her ) ) refusal to participate will not result in any penalty.
[Southern does not permit this paragraph; however it is included in the example as some institutions require it.] By signing this agreement, I do not waive any legal rights or relase [name of institution], its agents, or you from liability for negligence.
( [Parent's] [Guardian's] )Signature date
Phone number (optional)
Address (optional)
( [Child's] [Ward's] Name )
( [Child's birthdate] )
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