InformedConsentTemplate

Chandler-Gilbert | Estrella Mountain | GateWay | Glendale | Mesa Paradise Valley | Phoenix | Rio Salado | Scottsdale | South Mountain

The Maricopa County Community College District (MCCCD) is an EEO/AA institution and an equal opportunity employer of protected veterans and individuals with disabilities. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, or national origin. A lack of English language skills will not be a barrier to admission and participation in the career and technical education programs of the District. The Maricopa County Community College District does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs or activities. For Title IX/504 concerns, call the following number to reach the appointed coordinator: (480) 731-8499. For additional information, as well as a listing of all coordinators within the Maricopa College system, visit http://www.maricopa.edu/non-discrimination.

ThisistheofficialinformedconsenttemplateforresearchconductedwithintheMaricopaCountyCommunityCollegeDistrict.Allresearchersmustusethistemplate.Ifconsentisbeingsoughtthroughadigitalform(suchasthroughanonlinesurvey),theformatandcontentsofthistemplatemustbepreserved.Intheeventthatawaiverofconsentisreceived,researchparticipantsmuststillbeprovidedwithacopy(paperorelectronic)ofalloftheinformationcontainedherein.

Accordingtofederalregulations(45CFR46athttp://www.hhs.gov),informedconsentneedstobeprovidedtoparticipantsinamannerthatisclearandeasytounderstand.Thisincludesusinglanguagethatisappropriateforyouraudienceandavoidingtechnicalorscientificjargon.

Careshouldbetakentoensurethatprospectiveparticipantswithdisabilitieshaveequalaccesstoparticipateandareprovidedwithsufficientaccommodationstoensuretheyunderstandtheinformationcontainedintheinformedconsentdocumentpriortoseekingconsent.Forexample,considerusinglargerfontforthosewithvisualimpairments,andensurethatdigitalformsareaccessibleusingscreenreadertechnologies.

Allparticipantsshouldreceiveacopyofthisformfortheirownrecords.Ifconsentisbeingsoughtthroughadigitalform(suchasthroughanonlinesurvey),consideremailingacopyoftheformtoallparticipants.

Tobeusedasanassentform,pleaseincludealloftheinformationabouttheresearch,butremovethesignaturepageattheend.

Instructionsforfillingoutthistemplate:

Inthetemplatebelow,allpromptsforprovidinginformationaremandatory,andtheexactverbiagemustbeincludedinyourconsentform.Theinstructionsaredesignedtohelpyoufillinthenecessaryinformation,allowingyourresearchparticipantstomakeaninformeddecisionaboutparticipating.

Note:PleaseusethissheettoviewtheinstructionsonhowtofillintheInformedConsentForm.Ifyouneedadditionalassistancewiththeform,contactIRBatMaricopaCommunityColleges.

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StudyTitle:enterthetitleofthestudy

PrincipalInvestigator:includename&contactinformation

Youareinvitedtoparticipateinavoluntaryresearchstudyon(provideabriefdescriptionoftheresearch.Thisshouldbenomorethanonesentence.)

(Ifthisstudyisbeingfundedbyanexternalentity,pleaseprovideasentenceindicatingwhoisfundingthisresearch.)

Whyareyoudoingthisstudy?

Thepurposeofthisstudyis(Pleasedescribetheprojectinawaythatiseasytounderstand.Includethepurposeoftheresearch.)

WhatcanIexpecttodoifvolunteertoparticipateinthisstudy?

Asaparticipant,you(Pleaseprovideacleardescriptionofwhattheparticipantswillbedoingorexperience.)

Howmuchtimewillbeingaparticipanttake?

Byparticipatinginthisstudy,you(Pleaseindicatehowmuchtimetheparticipantswillbeexpectedtospendinthisstudy.Ifthestudyisdesignedtotakeplaceoveraperiodoftime,describethattimeperiodandthefrequencyofparticipation.)

ArethereanyrisksIshouldknowabout?

Note:Theinformationcollectedaboutyouwillonlybeusedforthisresearchandwillnotbesharedwithotherresearchersnoworinthefuture.

(Pleasedescribeanyrisks,includingpersonal,physical,mental/emotional,professional,financial,etc.Whatwouldbetherisksifthedatabecamepublic?Alsoincludewhatyouaredoingasaresearchertomitigatetheserisks.Ifthereareanycoststhattheparticipantswillincur,pleaseincludethosehere.)

(Includeasectionabouthowyou,astheresearcheraregoingtoprotecttheprivacyofparticipantinformation.Ifyouarecollectingbiospecimens,pleaseindicatehowyouwillprotectthesebiospecimens.)

(Iftheresearchinvolvesmorethanminimalrisk,pleaseclarifywhoisresponsibleforanycostsassociatedwithanymedicaltreatmentsrequiredoranypersonalcompensationforinjuriesreceivedasaresultofparticipationintheresearch.)

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Whatarethebenefitsforparticipating?

(Pleasedescribeanycompensation,monetaryorotherwise,thattheparticipantwillreceive.Ifnocompensationisbeingoffered,indicateassuch.Ifthereareexpectedbenefitstothepublicgood,suchasanincreasedunderstandingineffectivetreatments,indicatethishereaswell.Alsoindicateifyouorthefundingorganizationwillprofitfinanciallyfromthisstudy.Includewhetherornotparticipantswillshareintheseprofits.)

AmIeligibletoparticipate?

Tobeeligibletoparticipateinthisresearchstudy,you(Pleaseindicatetheeligibilityrequirementsforparticipatinginthisstudy.Ifyouarenotgoingtoseektheconsentofalegalguardianforminors,pleaseindicatethatparticipantsmustbe18orolder.)

WhatrightsdoIhaveasaparticipant?

Asaparticipant,youmaystopparticipatingatanytime.Selecttheoptionbelowthatappliestoyourparticipation:(Thefollowingareincludedsothattheparticipantsmaychooseanoption.)

Iamastudent.

Asastudent,ifyouchoosetostopparticipating,thiswillnotaffectyourclassgrades,academicstanding,financialaid,eligibilitytoparticipateinsportsorclubs,oryouremployabilitywithintheMaricopaCountyCommunityCollegeDistrict.Ifyoudecidenottoparticipate,youwillalsonotbeaffectedinanyway.

Iamanemployee.

Asanemployee,ifyouchoosetostopparticipating,thiswillnotaffectyouremploymentstatusoreligibilityforbenefits.Ifyoudecidenottoparticipate,youwillalsonotbeaffectedinanyway.

Iamafacultymember.

Asafacultymember,ifyouchoosetostopparticipating,thiswillnotaffectyouremploymentstatus,youreligibilityforbenefits,oryourabilitytoteachadditionalclasses.Ifyoudecidenottoparticipate,youwillalsonotbeaffectedinanyway.

Iftheparticipantshaveanyadditionalrightsaspertainingtothestudy,theyareoutlinedhere:

(Pleaseincludeanyadditionalrightsyourresearchparticipantswillhave.)

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WhodoIcontactifIhaveanyquestions?

Ifyouhavequestions,youmaycontact(Insertname,phonenumberandemailaddressofprincipalinvestigator.)

ThisresearchstudyhasbeenreviewedandapprovedbytheInstitutionalReviewBoard(IRB)fortheprotectionofhumanresearchparticipantsoftheMaricopaCountyCommunityCollegeDistrict.Ifyouhaveconcernsaboutthisstudy,oryoufeelthatyourrightshavebeenviolatedinanyway,pleasecontact:

MaricopaCommunityCollegesIRBOffice2411W14thStTempe,AZ85281irb_office@domail.maricopa.edu

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Consent

Ihavereadtheinformationprovided.IagreetoparticipateinthisresearchstudyandacknowledgethatImeettheeligibilityrequirementstobeaparticipant.(Note:Iftheparticipantisundertheageof18,seelegalguardiansignaturerequirementbelow.)

IfurtheracknowledgethatImaystopparticipatingatanytime.

_______________________________________

PrintedName

_______________________________________

Signature

_______________________________________

Date

(Iftheparticipantisunder18,signatureoftheguardianisrequiredinthefollowingsection.)

Theaboveparticipantisundertheageof18.Asthelegalguardianoftheparticipant,Igiveconsenttoallowparticipationintheresearch.(Note:Thesignatureofthelegalguardianisonlyrequiredwhenparticipantisundertheageof18.)

_______________________________________

PrintedName

_______________________________________

Signature

_______________________________________

Date

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AdditionalInformation:

(Ifyourequireadditionalspacetoprovideinformationaboutthestudy,pleaseenterthequestionfromaboveandprovidetheadditionalinformationinone,ormore,ofthefields.)