Example Format of a Short Form Consent for Non-Speakers of English
(This form is translated to the participant’s
language.)
Consent to Participate in a Research Study
You are being asked to participate in a research study.
Before you agree, the Investigator must tell you about
- The purpose of the research and how many people may participate in the research study
- Procedures to be performed and their duration
- Duration of the research study
- Which procedures are experimental
- If there are any foreseeable risks or discomforts to the research study and the possibility of any unforeseeable risks
- If there are any benefits of the research
- Any alternative procedures or treatments and
- how confidentiality will be maintained.
If applicable, the investigator must tell you about
- Any available compensation or medical treatment if injury occurs
- Any additional costs to you
- Circumstances when the investigator may stop your participation
- What happens if you stop your participation
- That you will told about any new findings that may affect your willingness to participate in the study.
Your participation in this research study is voluntary, and you will not be penalized or lose benefits if you refuse to participate or decide to stop participating in the study.
If you participate, you will be given a signed copy of this document.
You may contact ______________________ (name) at ______________
(phone number) any time you have questions about this research
study.
You may contact the HSIRB Office at 716-892-2752 if you have questions
about your rights as a participant in research.
By signing this document it means that the research study and the above information has been described to you orally, and that you voluntarily agree to participate.
| Signature of Participant: | ________________ | Date: | _____________ |
| Signature of Witness: | ________________ | Date: | _____________ |
| Signature of PI or Designee: | ________________ | Date: | _____________ |
