ࡱ> x{we >bjbj:: HXme\Xme\S2 LL8 ,84.llLO.Q.Q.Q.Q.Q.Q.$X14u.@u.LL.n n n RLRO.n O.n n r;)T"*KF˿R^);..0.)z44**4+*n u.u..4 > :  VALDOSTA STATE UNIVERSITY Consent to Participate in Research You are being asked to participate in a research project entitled Title of Project. This research project is being conducted by name of researcher(s), a faculty member/ staff member/ student in [discipline/department] at Valdosta State University. The purpose of this research is to describe the purpose of the study in lay terms. Your participation is entirely voluntary. As described in more detail below, we will ask you to [summarize the procedures for your participants in one or two sentences here]. Someone in your position might be interested in participating because [link participation to your studys direct or indirect benefits, [e.g. it may help reduce your anxiety symptoms, and will help us learn more about how to help people with anxiety in the future.]. Because there are some risks, such as [briefly discuss the risks here], you may not wish to participate. [If there is any other key information you think would be critical to a subjects decision of whether to participate, you should include that information here.] It is important for you to know that you can stop your participation at any time. More information about all aspects of this study is provided below. This form includes detailed information to help you decide whether to participate in this [study/research/project]. Please read it carefully and ask any questions that you have before you agree to participate. Please be sure to retain a copy of this form for your records. Procedures: Your participation will involve [please give a detailed description of what participants will be asked to do, taking care to use easily understandable terms. Ensure that you include a task-by-task and total time estimate (e.g. you will participate in three separate surveys which should each take 15 minutes. Your total participation in this project is expected to be 45 minutes)]. If you agree to participate, the researchers will also collect [discuss any data about the participant that you will gather that you are not receiving directly from them, as well as the source (e.g. gather information about your ACT scores, high school GPA, college major, and completed courses from the Registrars Office at your institution)]. Identify which, if any, of the procedures are experimental and indicate if there are any alternatives to the experimental procedures. If there are no alternatives to the experimental procedures, you may state, There are no alternatives to the experimental procedures in this study. The only alternative is to choose not to participate at all. If the study involves collection of research data about an educational strategy in a required course, be sure to differentiate clearly between the activities that are part of the research project and therefore voluntary and those that are required for course completion and academic credit. If the study involves concealment or deception, provide a general explanation of procedures in a statement similar to the following: There are some details about the study that you are not being told in advance. When your participation is over, the study will be explained to you in full detail, and all of your questions will be answered. At that time, you can decide whether or not you want your information to be used in the study. Possible Risks or Discomfort: This is a minimal risk research study. That means that the risks of participating are no more likely or serious than those you encounter in everyday activities. Identify possible discomforts or risks that the participant might experience, including minor issues such as embarrassment or uneasiness in dealing with sensitive issues. State the risk level (minimal or more than minimal), considering the probability and the magnitude of harm, as part of the explanation. Do not say that the study carries no risk for participants. If risks are unknown, the following statement may be used: Although there are no known risks associated with these research procedures, it is not always possible to identify all potential risks of participating in a research study. However, the University has taken reasonable safeguards to minimize potential but unknown risks. If the possibility of either physical or psychological injury exists, include this statement: If you [are injured/experience psychological distress] as a result of your participation in this study, please contact [researcher name] at [telephone number]. Neither the researcher nor Valdosta State University has made special provision for services required to treat any [injury/ psychological distress] that results from participation in this research study. If the study population includes Ӱý޹˾վ students and/or employees, add the following phrase to the above sentence: beyond those normally provided to Ӱý޹˾վ [students/employees]. As appropriate, Ӱý޹˾վ student participants should be informed that they may request counseling services from the Student Counseling Center at 229-333-5940 or health care services from Student Health Services at 229-333-5886. As appropriate, Ӱý޹˾վ employee participants should be informed that they may request counseling services from the Employee Assistance Program through Office of Human Resources & Employee Development at 229-333-5709 or health care services from their own private health care provider under their selected health insurance plan. If the participants are not Ӱý޹˾վ students or employees, you may provide contact information for community services, such as a community crisis hotline or an urgent care center. Indicate if the service is free to the participant or if the participant will be expected to pay for services rendered. The Possible Risks or Discomfort section should end with the following sentence: By agreeing to participate in this research project, you are not waiving any rights that you may have against Valdosta State University for injury resulting from negligence of the University or its researchers. Potential Benefits: Describe any anticipated or possible benefits to the participant and/or society. Be realistic in terms of both benefits for the participant and potential contribution to the discipline or society. The following phrase may be used when there are no direct benefits anticipated for the participant: Although you [may/will] not benefit directly from this research, your participation will help the researcher gain additional understanding of Knowledge gained may contribute to addressing Costs and Compensation: Describe any costs to the participant for participating in the research. (Note: One of the most common costs to participants is the cost of self-provided transportation to the research site.) Describe any compensation (money, gifts, or services outside of the research activity; inclusion in a lottery for any of the preceding types of compensation; or extra academic credit) that participants will receive. Provide details of how, when, and for what activities compensation will be provided. If there are no costs to participants or compensation for their participation, simply state: There are no costs to you and there is no compensation (no money, gifts, or services) for your participation in this research project. Be sure that any compensation offered is reasonable for the time, effort required of the participant, and that the compensation offered would not be viewed by the average person as being coercive. When offering extra credit for students participation in research, an alternative activity (such as review of a journal article or similar activity) may be substituted so that students do not feel pressured to participate in the research to qualify for extra credit. Make sure that the time and level of effort required for the alternate activity is not significantly greater than that required for participation in the research study.) Assurance of Confidentiality: Valdosta State University and the researcher will keep your information confidential to the extent allowed by law. Members of the Institutional Review Board (IRB), a university committee charged with reviewing research to ensure the rights and welfare of research participants, may be given access to your confidential information. If the study is funded by an external sponsor and the grant or contract gives the sponsor rights to participants research data, add, Representatives of [name of sponsor], which is providing financial support for this research, may also be given access to information about you. Describe how the participants information will be protected, including where it will be kept, who will have access to the information, how it will be protected from unauthorized access, how long it will be kept, and how it ultimately will be destroyed. Do not tell the participant that he/she will remain anonymous or his/her data will be anonymous if there is any way that you or anyone else can link the identity of the person to his/her information at any time during or after the study. Use of a code number linking identity and data, a video or audio recording, or capturing of an email address that can be linked to participant responses destroys the participants anonymity, even if the code list, recording, or email address is destroyed or deleted after receipt of information and/or entry of data into a database. Such action may render the data anonymous to any other individuals in the future, but this does not change the fact that the data were not anonymous to the researcher at an earlier time in the study. Instead, explain how you will ensure that information about the participant will be kept confidential and protected from unauthorized access. As appropriate, inform the participant how data from the study will be reported (e.g., reported in combination with information obtained from other participants, not associated with participants by name, not individually identifiable, use of pseudonyms, etc.). Voluntary Participation: Your decision to participate in this research project is entirely voluntary. If you agree now to participate and change your mind later, you are free to leave the study. Your decision not to participate at all or to stop participating at any time in the future will not have any effect on any rights you have or any services you are otherwise entitled to from Valdosta State University. If the participants are Ӱý޹˾վ students, indicate as appropriate that a decision not to participate will not affect their grades. If the study involves surveying or interviewing participants, add the following sentence: You may skip any questions that you do not want to answer. (Note that, if you are using an internet survey tool, it must be programmed to accept a non-response.) If the study involves collection or use of data that remains identifiable to the researcher, also inform participants that, should they decide to withdraw after data collection is complete, their information will be deleted from the database and will not be included in research results. If the study involves concealment or deception, reiterate the participants opportunity to decide whether to allow his/her data to be used in the study after his/her participation is over and the research has been fully explained. Information Contacts: Please use the following statement: Questions regarding the purpose or procedures of the research should be directed to [name of researcher] at [e-mail address]. This study has been approved by the Valdosta State University Institutional Review Board (IRB) for the Protection of Human Research Participants. The IRB, a university committee established by Federal law, is responsible for protecting the rights and welfare of research participants. If you have concerns or questions about your rights as a research participant, you may contact the IRB Administrator at 229-253-2947 or irb@valdosta.edu. Agreement to Participate: The research project and my role in it have been explained to me, and my questions have been answered to my satisfaction. I agree to participate in this study. By signing this form, I am indicating that I am 18 years of age or older. I have received a copy of this consent form. I would like to receive a copy of the results of this study: _____ Yes _____ No Mailing Address: ______________________________________________________________ E-mail Address: _______________________________  _________________________________________ Printed Name of Participant _________________________________________ Signature of Participant Date _________________________________________ Signature of Person Obtaining Consent Date     (Revised 01.21.2019) Consent to Participate in Research Page  PAGE 4 of  NUMPAGES 4 Participants Initials: __________ Ӱý޹˾վ MODEL INFORMED CONSENT FORM (Instructions: Use this model form when the IRB requires documentation of informed consent for research participants 18 years of age or older and who have the capacity to consent for themselves. Include non-italicized text in black typeface verbatim, and tailor the italicized text in black typeface to your study. Guidance for development of consent elements is provided in red typeface, with example wording in blue typeface. If there is more than one researcher conducting the study, use plural case as appropriate. Delete this header before saving and printing the final version of this form.) 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