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Parent Consent Form
University of St. Thomas 

[Insert Title of Study]

I am conducting a study about [insert general statement about the study]. I invite your child  to participate in this research.  Your child was selected as a possible participant because [explain how subject was identified].  Please read this form and ask any questions you may have before allowing your child to be in the study.

This study is being conducted by: [Indicate name of researcher, name of advisor, if applicable, Department affiliation].

Background Information:

The purpose of this study is: [Explain research question and purpose in clear, lay language.  You may also wish to explain the benefits of this research to people other than the subject]

Procedures:

If you allow your child to be in this study, I will him or her you to do the following things:  [Explain all tasks and procedures; subjects should be told about 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 [], Second, [] [Risk must be explained, including the likelihood of the risk and provisions made to minimize the risk.]

The direct benefits to your child for participating are: [If no benefit, state that fact here.  Explain only direct benefits to the subject]

Your child 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.  If there is no payment, omit this section.]

Compensation:

[If there is a physically invasive procedure, or an exercise component of this research, where there is even a slight risk of injury the following statement must be included in the consent form.]

In the event that this research activity results in an injury, treatment will be available, including first aid, emergency treatment and follow-up care as needed. Payment for any such treatment must be provided by you or your third party payor if any (such as health insurance, Medicare, etc.).

[Omit this section if there is no risk involved in the study objective.]

Confidentiality:

The records of this study will be kept private.  In any sort of report I publish, I will not include information that will make it possible to identify your child in any way.  Research records will be kept in a locked file; I am the only person who will have access to the records.  [If tape recordings or videotapes are made, explain who will have access, if they will be used for educational purposes, ands when they will be erased.]

Voluntary Nature of the Study:

Your child’s participation in this study is entirely voluntary. Your decision whether or not to allow him or her to participate will not affect your child’s or your own current or future relations with  [any cooperating institutions] or the University of St. Thomas.  If you decide to allow participation, you are free to withdraw your child from the study at any time without penalty.  Should you decide to withdraw your child from the study, data collected about him or her  [state whether or not you will use their data]

Contacts and Questions

My name is [insert researcher’s name].  You may ask any questions you have now.  If you have questions later, you may contact me at [telephone number]. [If the researcher is a student, include advisor’s name and telephone number here.]  You may also contact the University of St. Thomas Institutional Review Board  at 651-962-5341 with any questions or concerns.

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

Statement of Consent:

I have read the above information.  My questions have been answered to my satisfaction.  I give consent for my child to participate in the study.

______________________________                                  ________________
Signature of Parent or Guardian                                           Date
            (If applicable)

______________________________                                   ________________
Signature of Study Participant                                              Date
[use this if a separate child assent
form is not used].

______________________________                                  ________________
Signature of Researcher                                                        Date