Page 1 of 3 Reviewed/revised: November 2023. Form available here: O:/SourcesPublic/SourcesForms. 5D CONSENT TO PARTICIPATE IN RESEARCH [INSERT TITLE OF STUDY] If the study requires different consent forms for different populations, identify the population group as the subtitle of the study. You are asked to participate in a research study conducted by [insert names of all investigators, including job titles], from [insert program] of Sources. [If applicable, identify sponsoring agency(ies)/organization(s)] If you have any questions or concerns about the research, please contact: [insert contact person(s), including phone # or email] PURPOSE OF THE STUDY [State (in plain language) what the study is designed to assess or establish.] PROCEDURES If you volunteer to participate in this study, we will ask you to do the following: [Describe the procedures chronologically using plain language, short sentences, and short paragraphs. D e f i n e medical/scientific terms. Identify experimental procedures)] [Specify the participant’s assignment to study groups, length of time for participation in each procedure, the total length of time for participation, frequency of procedures, location of the procedures to be done, etc. Provide details about any plan to contact participants for followup sessions or subsequent related study. Include a statement of whether research findings will be available to participants and how/where they will be made available.] POTENTIAL RISKS AND DISCOMFORTS [Describe any reasonably foreseeable risks, discomforts, inconveniences (including physical, psychological, emotional, financial, and social), and how these will be managed.] [State any rare, but catastrophic effects that the participant may experience.] [Describe any significant physical or psychological risks to participants that might cause the researcher to terminate the study.] POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY [Describe benefits to participants expected from the research. If the participant will not benefit from participation, clearly state this fact. Also state the potential benefits, if any, to science or society expected from the research.]
Page 2 of 3 Reviewed/revised: November 2023. Form available here: O:/SourcesPublic/SourcesForms. PAYMENT FOR PARTICIPATION [State whether the participant will receive payment or not. If participant will receive payment, describe remuneration amount.] CONFIDENTIALITY Every effort will be made to ensure confidentiality of any identifying information that is obtained in connection with this study. [Describe procedures to ensure confidentiality of data an of participants. Provide information on length of retention and security of data. If information will be released to a third party, state the person/agency to whom the information will be provided, nature of the information, and purpose of the disclosure.] [If activities will be recorded (audio or video) describe the participant’s right to review/edit the recording/transcripts, who will have access, if they will be used for educational purposes, and when they will be erased.] PARTICIPATION AND WITHDRAWAL You can choose whether to be in this study or not. If you are receiving or applying for services from Sources, your decision to participate, or not, will not affect the services you are receiving or applying for. If you volunteer to be in this study, you may withdraw at any time without any consequences. You may exercise the option of removing your data from the study. You may also refuse to answer any questions you do not want to answer and remain in the study. The investigator may withdraw you from this research if circumstances arise that warrant doing so. [If appropriate, describe the anticipated circumstances under which the participant’s involvement may be terminated by the investigator without regard to the participant’s consent.] RIGHTS OF RESEARCH PARTICIPANTS You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims, rights, or remedies because of your participation in this study. This study has been reviewed and received ethics clearance through Sources’ Executive Team. If you have questions regarding your rights as a research participant, contact: [Insert contact name and contact info here]
Page 3 of 3 Reviewed/revised: November 2023. Form available here: O:/SourcesPublic/SourcesForms. SIGNATURE OF RESEARCH PARTICIPANT/LEGAL REPRESENTATIVE I have read the information provided for the study “[insert title]” as described herein. My questions have been answered to my satisfaction, and I voluntarily agree to participate in this study. I have been given a copy of this form. Name of Participant (please print) _______________________________ Name of Legal Representative (if applicable) _____________________ Signature of Participant or Legal Representative ___________________ The name and signature of the legal representative is ONLY necessary if the participant is not competent to consent. If the participant is competent, do not include this option. Date________________ Name of Witness (please print) _________________________________ Signature of Witness _________________________________________ Ideally, the investigator is not also the witness. If no other options are available, the investigator can act as witness. Date ________________