ࡱ> HcGk j%bjbjZ Z 0D8cb8cb IRRRRRfff8T,f"4RRR9";";";";";";"$d$'_"R_"RRRR4t"XXXRRRRR9"X9"XXV @)!R  %""0" 0'')!'R)!X_"_""'B : CONSENT TO PARTICIPATE IN RESEARCH (Minor Assent 13-17) Please read this assent agreement with your parent(s) or guardian(s) before you decide to participate in the study. Your parent or guardian will also give permission to let you participate in the study. Project Title: (Insert title.) Researcher(s): (Insert name of researcher(s).) Faculty Sponsor: (Include the sponsors name if the research is being conducted by a student.) Introduction: For faculty or staff project state the following: We are asking you to take part in a research study by (researchers name), a faculty (or staff) member in the Department of (insert department) at Loyola University of Chicago. For a student project state the following: We are asking you to take part in research by (student name) for a (indicate whether this is a class project, thesis, dissertation) guided by (faculty sponsor) in the Department of (insert department) at Loyola University of Chicago. You are being asked to participate because (Making sure that all language is appropriate to the reading level of the child, explain why the person is being asked to participate. For example, if the person is being asked because he or she is a member of a particular group, has had a particular experience, or possesses certain characteristics, explain this here. When appropriate, give the approximate number of participants in the study and describe any exclusion criteria, e.g., age limit, health restrictions, etc.). Please read this form carefully and ask any questions you may have before deciding whether to participate in the study. Purpose: We want to learn about (Explain the research question or purpose in lay language at an appropriate reading level.). Procedures: If you agree to be in the study, you will be asked to: Explain all tasks and procedures in a language that the child can understand and in sufficient detail. For example, if the participants will be asked to participate in an interview, explain the subject matter of the interview, the topic areas that will be covered or types of questions that will be asked, how long it will take, where it will be held, etc. If the interview will be audiotaped or videotaped, state this. Tell the participants approximately how many people will be involved in the study If the research involves more than one procedure, (i.e. an interview and a survey), use bullet points to list and explain each procedure separately. If the research involves different experimental groups, explain how participants will be assigned to groups. Risks/Benefits: Explain any foreseeable risks or discomforts. If there are no foreseeable risks, you may simply state: We dont think that there are any risks to you in this study. Explain any benefits to the participant or to society. If the participant will not benefit directly, simply state: If you participate in this study, there wont be any benefit to you, but (indicate how the results may be helpful to others or to society). Financial compensation should not be discussed here, but should be in a separate section. Compensation: (optional section) Include this section only if participants will be compensated in some way, (e.g., money, gift certificate, extra credit for a class, etc.). Describe the amount or nature of the compensation and indicate how compensation will be handled if they withdraw. If compensation includes a drawing or raffle, note the odds of winning. Make sure to state if compensation will be given to the child or to the parent. Costs: (optional section) Include this section only if there are special costs to the participant for participation, (e.g., the participants must pay for an activity, etc. In this case, describe the anticipated costs). Alternatives: (optional section) Include this section only if this study involves an intervention or a diagnostic procedure and there are alternatives that the person may consider. In this case, explain the alternatives to participating in the research. For example, if there are other interventions or diagnostic procedures that the person may choose, describe them. Confidentiality: Explain the degree to which information gathered will be confidential and explain how it will be kept confidential, (i.e. if data will be coded so that no names appear on any questionnaires, explain the coding system). If there are limits to confidentiality, explain these, (e.g., if you are a licensed professional and thus required to report child/elder abuse or neglect, this should be disclosed if the study is likely to elicit reportable information; if others, besides the researcher(s), will have access to the data indicate who will have access, etc.). If de-identified data will be shared to meet open source standards, note this and describe the steps that will be taken to ensure confidentiality and any limits to confidentiality. If focus groups are part of the procedure, please note that you will ask everyone to keep everything said during the focus group confidential, but confidentiality cannot be guaranteed. If audio or video recordings will be made during the course of the research, explain how the recordings will be stored and what will happen to the recordings at the conclusion of the research. ONLY IF USING A SIGNED CONSENT, provide a separate place for the participant to note if they are willing to be audio/video recorded, if the recording is optional for participation. For example: Please initial below if you are willing to have this interview recorded (specify audio or video). You may still participate in this study if you are not willing to have the interview recorded. ______ I do not want to have this interview recorded. ______ I am willing to have this interview recorded. Voluntary Participation: You can stop doing the study at any time. There is no penalty for stopping. (If participants currently have a relationship with the researcher or are receiving services from the cooperating research institution, state that their decision to participate or not will have no affect on their current relationship, the services they are currently receiving, etc.) Contacts and Questions: If you have questions about this research study, please feel free to contact (insert name of researcher) at (insert business phone number or email). If this is a student project, give contact information for both the student researcher and the faculty sponsor, (e.g. If you have questions about this research project or interview, feel free to contact___ at___ or the faculty sponsor___ at___.). If you have questions about your rights as a research participant, you may contact the Loyola University Office of Research Services at (773) 508-2689. Statement of Consent: I agree to participate in the research study described above. You will be given a copy of this form to keep for your records. ____________________________________________ __________________ Participants Signature Date ____________________________________________ ___________________ Researchers Signature Date Revision Date: XX/XX/202X (Each time a new version of this form is submitted for review, this date must be updated. 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