CONSENT TO PARTICIPATE IN A RESEARCH STUDYONLINE SURVEY WELCOME

  AUTHORIZATION AND CONSENT FOR DISCLOSURE OF CRIMINAL
APPENDIX H SURROGATE CONSENT PROCESS ADDENDUM THE
BUILDING PLATFORM CHECKLIST (VERSION NOV2019) RESOURCE CONSENT NO

CONSENTIMIENTO INFORMADO PARA LA UTILIZACIÓN DE MUESTRAS BIOLÓGICAS
ELECTROCONVULSIVE THERAPY (ECT) YOUR RIGHTS ABOUT CONSENT
INFORMED CONSENT FORM AND HIPAA AUTHORIZATION STUDY

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

Consent to Participate in a Research Study-Online Survey


Welcome to the “Title of Your Survey”



Researcher X and Dr. ---- of the Chicago State University, Department of ----- invite you to be a part of a research study that looks at -------------------------. The purpose of the study is to -------------. We are asking you to participate because --------------.


If you agree to be part of the research study, you will be asked to complete an online survey about --------. We expect this survey to take -- to -- minutes to complete. Some of the survey questions ask about ---- and may be distressing to you as you think about your experiences. If you need to talk to someone about these feelings, please contact: (Provide a list a resource for community counseling agency or national hotline).


Participating in this study is completely voluntary. Even if you decide to participate now, you may change your mind and stop at any time. You may choose to not answer an individual question or you may skip any section of the survey. Simply click “Next” at the bottom of the survey page to move to the next question.


While you may not receive any direct benefit for participating, we hope that this study will contribute to the improvement of ---------.


Researchers will not be able to link your survey responses to you. The survey software has been set so that no identifying information is captured. We may publish the results of this study, but we will not include any information that would identify you.


If you have questions about this research study, you can contact Researcher X., Chicago State University, Department of ----, address, Chicago, IL, (773) phone number or [email protected].


The Chicago State University Institutional Review Board has determined that this study is exempt from IRB oversight. If you have any questions for the Institutional Review Board please email their office at [email protected] or call at (773) 995-2405.


By clicking on “Yes, I agree to participate”, you are consenting to participate in this research survey.


If you do not wish to participate, select “No, I do not wish to participate” to exit the survey.


Template updated 1-21-2019


PATIENT ID NUMBER PATIENT NAME INFORMED CONSENT
TERMO DE CONSENTIMENTO DE USO DE BANCO DE
(REV 10919) INFORMED CONSENT FORM (ICF) TEMPLATE INFORMED CONSENT


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