Institutional Review Board: Sample Consent Forms

The following forms are available in both MS Word and Adobe PDF file formats:

• Sample Written Consent Form for Adults - Word / PDF
• Sample Consent Form for Adults for Minors - Word / PDF 
• Sample Consent Form for Minors - Word / PDF
• Sample Cover Letter for Anonymous, Non-Sensitive Questionnaires - Word / PDF

Or you may copy the texts below and paste them on to any text editing program of your choice:

• Sample Written Consent Form for Adults
• Sample Consent Form for Adults for Minors
• Sample Consent Form for Minors
• Sample Cover Letter for Anonymous, Non-Sensitive  

Sample Written Consent Form for Adults

You are invited to participate in a research study conducted by [name of investigator(s)], from the UNIVERSITY OF PORTLAND [departmental affiliation(s)].  I hope to learn [state what the study is designed to discover or establish].  You were selected as a possible participant in this study because [state why subject was selected].

If you decide to participate, [describe procedures, including their purpose, how long they will take, their location and frequency.  If activities are to be audio or videotaped, indicate this].

[Describe risks, discomforts, inconveniences, and how these will be managed.  Describe any alternative procedures or courses of treatment, if applicable.  Indicate costs of participating, if any].  [Describe benefits to subjects and humanity expected from the research].  However, I cannot guarantee that you personally will receive any benefits from this research.  [If subject will receive compensation, describe amount and when payment is scheduled].

Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law.  Subject identities will be kept confidential by [describe coding procedures and plans to safeguard data]. [If participants will remain anonymous, then reword the above to reflect that and state how the information will be kept anonymous.]  [If information will be released to any other, for any reason, state the personal agency to whom the information will be furnished, the nature of the information, and the purpose of the disclosure].

(If federally funded, include the following.) This study is being funded by a federal agency which requires that data be collected in a form that may be analyzed for differences between men and women and races or ethnic groups. 

Your participation is voluntary.  Your decision whether or not to participate will not affect your relationship with [name agency, school, etc.  where subject was recruited].  If you decide to participate, you are free to withdraw your consent and discontinue participation at any time without penalty.

If you have any questions about the study, please feel free to contact [phone number, e-mail, and address].  [If student, also provide advisor name and phone, and identify as your advisor].  If you have questions regarding your rights as a research subject, please contact the IRB (IRB@up.edu).  You will be offered a copy of this form to keep.

Your signature indicates that you have read and understand the information provided above, that you willingly agree to participate, that you may withdraw your consent at any time and discontinue participation without penalty, that you will receive a copy of this form, and that you are not waiving any legal claims.

Signature
Date

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Sample Consent Form for Adults for Minors

*Note: Parents, legal guardians, or a legally authorized official MUST sign consent forms permitting minors to participate in research projects.  Depending on the age of the minor, you may wish to have the minor sign an informed consent document. The form signed by the minor is more for informational purposes and to make the minor feel more involved in the study. It CANNOT substitute for the adult authorization form, but merely supplement it.

GUARDIAN AUTHORIZATION:

Your child is invited to participate in a research study conducted by [name of investigator(s)], from the UNIVERSITY OF PORTLAND [departmental affiliation(s)].  I hope to learn [state what the study is designed to discover or establish].  Your child was selected as a possible participant in this study because [state why subject was selected].

If you decide to allow your child to participate, [describe procedures, including their purpose, how long they will take, their location and frequency.  If activities are to be audio or videotaped, indicate this].

[Describe risks, discomforts, inconveniences, and how these will be managed.  Describe any alternative procedures or courses of treatment, if applicable.  Indicate costs of participating, if any].  [Describe benefits to subjects and humanity expected from the research].  However, I cannot guarantee that your child personally will receive any benefits from this research.  [If subject will receive compensation, describe amount and when payment is scheduled].

Any information that is obtained in connection with this study and that can be identified with your child will remain confidential and will be disclosed only with your permission or as required by law.  Subject identities will be kept confidential by [describe coding procedures and plans to safeguard data].  [If information will be released to any other, for any reason, state the personal agency to whom the information will be furnished, the nature of the information, and the purpose of the disclosure].

(If federally funded, include the following.) This study is being funded by a federal agency which requires that data be collected in a form that may be analyzed for differences between men and women and races or ethnic groups. 

Your child’s participation is voluntary.  Your decision whether or not to allow our child to participate will not affect your or your child’s relationship with [name agency, school, etc.  where subject was recruited].  If you decide to allow your child to participate, you and/or your child are free to withdraw your consent and discontinue participation at any time without penalty.

If you have any questions about the study, please feel free to contact [phone number, email and address].  [If student, also provide advisor name and phone, and identify as your advisor].  If you have questions regarding your rights as a research subject, please contact the IRB (irb@up.edu).  You will be offered a copy of this form to keep.

Your signature indicates that you have read and understand the information provided above, that you willingly agree to allow your child to participate, that you and/or your child may withdraw your consent at any time and discontinue participation without penalty, that you will receive a copy of this form, and that you are not waiving any legal claims.

Signature
Date

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Sample Consent Form for Minors

*Note: Parents, legal guardians, or a legally authorized official must sign consent forms permitting minors to participate in research projects.  The informed consent document for minors must be prepared with the same thoroughness as the informed consent document for adults.

[Make reading level appropriate for the age of the children.]

I am willing to take part in the study called (name of study).  I understand that the researchers from (name the institution) are hoping to (describe the purpose of the study in simple terms.) I understand that I will do (describe the actions that will be undertaken by a subject, where they will take place, and other situational factors such as audio- or video-taping).  I will be asked about (describe the sorts of questions the subject will be asked).  This study will take place (name the location of the study) and should take about (estimate of time involvement) of my time.

I am taking part because I want to.  I have been told that I can stop at any time, and if I do not like a question, I do not have to answer it.  No one will know my answers, including (name people that will not have access to answers, i.e., strangers, parents, other children, etc.)

Name _____________________

Signature __________________

Date: _____________________

Age: ________

 

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Sample Cover Letter for Anonymous, Non-Sensitive Questionnaires

I would appreciate your assistance with this research project on [state purpose of research, indicate how results will be used, and indicate how results will be reported].  This research will help me understand [state benefits to subjects and humanity expected from the research].

All you need to do is complete this short questionnaire, which should take approximately [state time needed to complete questionnaire].  If you do not wish to participate, simply discard the questionnaire.  Responses will be completely anonymous; your name will not appear anywhere on the survey.  Completing and returning the questionnaire constitutes your consent to participate.

Keep this letter for your records.  If you have any questions regarding the research, contact [give name, department, phone number, address.  Include advisor telephone if student, and identify as advisor].  If you have any questions regarding your rights as a research participant, please contact the Institutional Review Board office at the University of Portland.  Thank you again for your help.