ࡱ> orne >bjbj:: HXme\Xme\2 8<.LNNN/.1.1.1.1.1.1.$813U.V@U.NNj.RRNN/./.rw(Tf"S)N^(..0.(z~4F~4S)~4S)U.U..~4 > :  AV Parent/Guardian Permission for Childs/Wards Participation in Research You are being asked to allow your child (or ward) to participate in a research study entitled Title of Project. This research study is being conducted by name of researcher(s), a faculty member/ staff member/ student in [discipline/department] at AV. The purpose of this research is to describe the purpose of the study in lay terms. Your childs participation in this study is entirely voluntary. From this point on in this form, the term child is used for either a child or a ward. As described in more detail below, we will ask your child to [summarize the procedures for your participants in one or two sentences here]. Your childs participation will last for total time estimate (e.g. approximately 20 minutes). Someone in your position might be interested in allowing your child to participate because [link participation to your studys direct or indirect benefits, [e.g. it may help reduce 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 allow your child to participate. [If there is any other key information you think would be critical to a parent/subjects decision of whether to participate, you should include that information here. It is important for you to know that you or your child may discontinue participation at any time during this study. 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 childs 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 [if applicable, discuss any data about the participant that will be gathered that you are not receiving directly from them, as well as the source (e.g. gather information about ACT scores, high school GPA, college major, and completed courses from the Registrars Office at your institution)]. You or your child may discontinue participation at any time during this study regardless of the reason. All direct interaction with your child will occur [Indicate where] (e.g. at the AV Speech and Hearing Clinic, during your childs regularly scheduled speech therapy time, or during their afterschool program). This study involves research. There are no alternatives to the experimental procedures in this study. The only alternative is for you to choose not to allow your child to participate. 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. Although there are no known risks to your child associated with the 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. 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 or your child may have against AV for injury resulting from negligence of the University or its researchers. 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 AV has made special provision for services required to treat any [injury/ psychological distress] that results from participation in this research study. If the participants are not AV 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. 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: AV and the researcher will keep your childs 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 childs confidential information. 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. (e.g. Your child will be assigned a code number as a way to identify and keep track of data. Numbers assigned to your child with not be associated with his/her name or any other identifying information. This is to ensure that individuals remain unidentifiable. Your childs birth date will be recorded as a way to calculate your childs chronological age in order to interpret scores and results of this study. All information obtained from testing will be kept in the researchers office secured by lock and key. Only those individuals that YOU choose to share the results with will have access to the results). 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.) (e.g. Data from this study will be reported in combination with testing information obtained from other participants. None of the participants will be identified in this study by name or birth date.) Voluntary Participation: Your decision to allow your child to participate in this research project is entirely voluntary. If you agree now to allow your child to participate and you change your mind later, you are free to withdraw your child from the study at that time. By not allowing your child to participate in this study or by withdrawing him/her from the study before the research is complete, you are not giving up any rights that you or your child have or any services to which you or your child are otherwise entitled to from AV. If you decide to withdraw your child from the study after data collection is complete, your childs information will be deleted from the database and will not be included in research results. 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. 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 AV 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  HYPERLINK "mailto:irb@valdosta.edu" irb@valdosta.edu. Agreement to Participate: The research project and my childs (or wards) role in it have been explained to me, and my questions have been answered to my satisfaction. I grant permission for my child to participate in this study. By signing this form, I am indicating that I am either the custodial parent or legal guardian of the child. I have received a copy of this permission form. I would like to receive a copy of the results of this study: _____ Yes _____ No Mailing Address: ______________________________________________________________  E-mail Address: _______________________________ _________________________________________ Printed Name of Child/Ward _________________________________________ Printed Name of Parent/Guardian _________________________________________ Signature of Parent/Guardian Date _________________________________________ Signature of Person Obtaining Consent Date     (Revised 01.21.2019) Permission for Child Participation in Research Page  PAGE 4 of  NUMPAGES 4 Parent/Guardians Initials: __________ Parent/Guardian Consent Template (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.) 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