ࡱ> 241 (bjbjWW 8 55 2\\8u22(ZZZ555$55555ZZ/5RZZ5hZ&n' Td4E0u<,wwhwhx5555555555u5555w555555555\ |: SAMPLE INFORMED CONSENT FORM FOR ADULTS This document may serve as a guide or a template for your actual Informed Consent or Informational Letter. All the information in this sample form must be included in the Informed Consent or Informational Letter submitted to IRB for review. You may choose your own format if desired. INFORMATION ABOUT: give title of study BALDWIN WALLACE UNIVERSITY BEREA, OHIO 44017 RESPONSIBLE INVESTIGATOR: give name of responsible investigator and co-investigator DATE OF PREPARATION OR REVISION: I have been asked to participate in a research study that investigates describe purpose of investigation, how it relates to other knowledge on the topic(s) and what use may be made of the results obtained In participating in this study I agree to describe briefly and in lay terms procedures to which participant is consenting. Be specific in describing treatments or tests, how often and how much given, time limits of study, invasive techniques, any restrictions on normal activities, long term follow-up examinations or the possibility of receiving inactive material in a double-blind trial. The subject should understand exactly what they are agreeing to do by consenting to be in this study. I understand that: a) The possible risks of this procedure include list known risks or side effects: if none, so state; if unpredictable, so state; include measures that will be taken to minimize hazard or discomfort. b) The possible benefits of this study to me are known treatment benefits; if none, so state. c) Any questions I have concerning my participation in this study will be answered by first and last name(s) and degree(s) of investigator(s) available to answer questions and phone number(s) where the person may be contacted. d) I understand that I may refuse to participate or may withdraw from this study at any time without any negative consequences. Also, the investigator may stop the study at any time. I also understand that no information which identifies me will be released without my separate consent, and that all identifiable information will be protected to the limits allowed by law. If the study design or the use of the data is to be changed, I will be so informed and my consent re-obtained. I understand that if I have any questions, comments, or concerns about the study or the informed consent process, I may write or call the Office of the Provost, , 275 Eastland Road, Berea, Ohio 44017, 440-826-2251. I acknowledge that I have received a copy of this form. e) I have received a copy of or access to this consent form. f) This study is supported by funding from funding source must be listed only if is a commercial company. I have read the above and understand it and hereby consent to the procedure(s) set forth. Participant (printed name): ________________________________ Participant (signature): ____________________________________ Date: ______________ Investigator (signature): ___________________________________     Page  PAGE 1 of  NUMPAGES 1 '(D E W X Y l n  Z - . 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I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] (   1114] ( ( +-4!8@0(  B S  ?!'  & ) ( " 0  & ) 33'3 @ R R _ ` a     # $ ) 'ihh^`OJQJo(hHh^`OJQJ^Jo(hHohr ^r `OJQJo(hHhB^B`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohR^R`OJQJo(hH'i         XRD5, 53Ee?`A?tKNA}RvNY$bm+fUzyzs s6F7KN:kH`\? @''''( @UnknownG*Ax Times New Roman5Symbol3. *Cx Arial3*Ax Times?= *Cx Courier New;WingdingsA$BCambria Math"h'$J$g - - x20 [ 3qHX $Ps2!xx SAMPLE INFORMED CONSENT FORMATBaldwin Wallace College Jaimy Dyer Oh+'0   @ L Xdlt| SAMPLE INFORMED CONSENT FORMATBaldwin Wallace CollegeNormal Jaimy Dyer8Microsoft Office Word@e@6[O@6 T- ՜.+,0 hp  Baldwin-Wallace College  SAMPLE INFORMED CONSENT FORMAT Title  "#$%&'(*+,-./03Root Entry F@v' T51TableWordDocument8 SummaryInformation(!DocumentSummaryInformation8)CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q