DRAFT

The project director should adapt the following text, providing information as indicated by the square brackets, and attach the completed document to the Request for IRB Review.

INFORMED CONSENT

I, _________________________________ (please print name) hereby consent to my participation in this research project.

This study involves an investigation of [project title, or explanatory paraphrase]. I understand that all of my responses in this study are completely confidential and will be used only for research purposes. I understand that my participation in this project is completely voluntary. I further understand that I am free to withdraw my participation at any time without any penalty.

The benefits of this project are [state briefly what the expected benefits of the study are]. The potential risks are [state briefly any risks associated with the study]. [Alternatively, if appropriate, you may state that there are no potential risks anticipated.]

If I have any questions regarding this project or wish to have further information, I am free to contact [project director's name] in the [name of department] at Trinity College [give contact telephone number also].

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Signature                                                                                    Date