Anda di halaman 1dari 2

Stanford University Informed Consent Form TEM-C7n

Instructions are in red; bolded items must be included.

Before submission to the IB! emove instructions and any bold em"hasis.
Protocol Director: (Only protocol directors or faculty sponsors whose names appear in the
Personnel Info section of the eProtocol application may be listed here).
DESCRIPTION: #ou are invited to "artici"ate in a research std! on $describe project in
non-technical language; include types of questions that will be ased! if applicable; e"plain
purpose of the research). #ou %ill be as&ed to (describe procedures; mention #ideo$audio
taping! if applicable! and what will become of tapes after use! e.g.! shown at scientific meetings;
describe the final disposition of the tapes).
TI"E IN#OL#E"ENT: #our "artici"ation %ill ta&e a""ro'imately (insert duration).
RIS$S %ND &ENEFITS: The ris&s associated %ith this study are (describe foreseeable risks
to participants; if none! state as such). The benefits %hich may reasonably be e'"ected to result
from this study are (describe any benefits; if none! state as such). 'e cannot and do not
(arantee or )romise that !o *ill recei+e an! benefits from this std!, (If applicable) #our
decision %hether or not to "artici"ate in this study %ill not affect your (choose as appropriate)%
employment; medical care; grades in school.
P%Y"ENTS: #ou %ill receive (describe reimbursement; where there is none! state as such) as
"ayment for your "artici"ation.
SU&-ECT.S RI/0TS: If you have read this form and have decided to "artici"ate in this
"ro(ect) "lease understand your )artici)ation is +olntar! and you have the ri(ht to *ithdra*
!or consent or discontine )artici)ation at an! time *ithot )enalt! or loss of benefits to
*hich !o are other*ise entitled. The alternati+e is not to )artici)ate, #ou have the ri*ht to
refuse to ans%er "articular +uestions. #our individual "rivacy %ill be maintained in all "ublished
and %ritten data resultin* from the study. (If identities will be disclosed! pro#ide details! ,ith
your "ermission) your identity %ill be made &no%n in %ritten materials resultin* from the study.-
Questions: If you have any +uestions) concerns or com"laints about this research) its "rocedures)
ris&s and benefits) contact the .rotocol /irector) (name and phone number of Protocol &irector).
Independent Contact: If you are not satisfied %ith ho% this study is bein* conducted) or if you
have any concerns) com"laints) or *eneral +uestions about the research or your ri*hts as a
"artici"ant) "lease contact the Stanford Institutional evie% Board $IB- to s"ea& to someone
inde"endent of the research team at $012--734-3562 or toll free at 7-600-062-3820. #ou can also
%rite to the Stanford IB) Stanford University) MC 1178) .alo 9lto) C9 85425.
(If applicable) Appointment Contact: If you need to chan*e your a""ointment) "lease contact
$name- at $phone number-.
(If applicable) I *ive consent to be audiota"ed durin* this study.
.lease initial! :::#es :::;o
(If applicable) I *ive consent to be videota"ed durin* this study!
.lease initial! :::#es :::;o
(If applicable) I *ive consent for ta"es resultin* from this study to be used for (describe proposed
use of tapes)!
<ile!TEM23C27 rev7 25=33=72 7 of 3
Stanford University Informed Consent Form TEM-C7n

.lease initial! :::#es :::;o
(If applicable) I *ive consent for my identity to be revealed in %ritten materials resultin* from
this study!
.lease initial! :::#es :::;o
The e1tra co)! of this consent form is for !o to 2ee),
SI/N%TURE 33333333333333333333333333333 D%TE 333333333333
Protocol %))ro+al Date:
Protocol E1)iration Date:
<ile!TEM23C27 rev7 25=33=72 3 of 3