[INSERT ELECTRONIC DEPARTMENT LETTERHEAD ON PAGE 1] PERMISSION FORM

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INSERT DATE OF LETTER] [INSERT SCHOOL DISTRICT NAME AND

[INSERT DATE (PRIOR TO AUGUST 10 2009)] [INSERT SCHOOL
[INSERT DATE PRIOR TO AUGUST 24 2010] [INSERT SCHOOL
10 INFORMATION MANAGEMENT AGREEMENT BETWEEN [INSERT PHYSICIAN

Sample consent form for behavioral study:

[INSERT ELECTRONIC DEPARTMENT LETTERHEAD ON PAGE 1]


Permission Form Template v. 4/05/2016

The information highlighted in yellow is guidance and/or additional clarification of the federal requirements.

DELETE THIS AND ALL OTHER HIGHLIGHTED INSTRUCTIONS before submitting.


RSRB Requirements:


Permission Form


[Insert Title of Study]


Principal Investigator: [Insert]



This permission form describes a research study, what you may expect if you decide to allow your child to take part and important information to help you make your decision. Please read this form carefully.


The study staff will explain this study to you. Please ask questions about anything that is not clear before you decide whether or not you and your child want to participate. You may take this permission form home to think about and discuss with family or friends.



Introduction

Your child is being asked to take part in this study because…Specify condition, circumstance, or other reason for recruitment to study.


This study is being conducted by [insert investigator names] of the University of Rochester’s Department of [insert department name].


Purpose of Study

The purpose of this study is to…Describe the general purpose of the study and include relevant background information in lay terms. If possible, limit the explanation to why study is being done to one or two sentences.

NOTE: Sample language for certain procedures and related risks (e.g., blood draws, interviews, questionnaires, tissue banking, etc.) is provided in the RSRB Consent Document Sample Language guide.


Description of Study Procedures

If you decide to allow your child to take part in this study, they will be asked to…Describe in plain language (i.e., using lay terms), step-by-step, what will be done or required of the research subject. Be concise; avoid describing study procedures in lengthy narrative form. All procedures should be listed in the permission form. If there are multiple steps, use sub-headings, bullets, tables, pictures, etc. Include where the study procedures will take place. If different procedures will take place at different locations, specify accordingly.


(If applicable for documenting study participation in electronic health record)

The following information about your child’s study participation will be included in your child’s electronic health record:


(If applicable for documenting study participation and research results in electronic health record)

The following information about your child’s study participation will be included in your child’s electronic health record:


Number of Subjects

Approximately [state total accrual goal (number) here] subjects will take part in this study. If appropriate, give a short description about cohorts. If this is a multi-center study, provide figures for both the whole study and for local enrollment at UR (e.g., “Approximately 40 subjects from 4 study centers across the country will take part in this research. Locally, about 20 subjects will participate.”).


Duration of the Study

Your child’s participation in the study will last…Indicate the length of time of the individual subject’s active involvement. If not previously stated in the procedures section, include the expected time needed for study visits/procedures as well as the overall length of time.


Risks of Participation

**The risks listed in the permission from should be consistent with the protocol and application.**


For each research procedure, describe immediate and long-term physical, psychological, and social risks/discomforts. Provide sufficient description of the risks to enable parents to decide whether they want their child to participate. If appropriate, include information on probability of the risks and the magnitude and reversibility of harmful effects. Describe how the researchers are minimizing the risks/discomforts. If there are currently unforeseeable risks to the subject (or fetus, if the subject may become pregnant), this should be stated.


For applicable FDA-regulated studies include the following statement (to determine if this applies to your study see: http://prsinfo.clinicaltrials.gov/s801-fact-sheet.pdf; contact the CTSI’s Office of Regulatory Support for questions or help with registration): “A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by U.S. Law. This Web site will not include information that can identify your child. At most, the Web site will include a summary of the results. You can search this website at any time.”


(If applicable for documenting study participation in electronic health record)

The study team may be notified if your child receives other health care services at URMC and Affiliates (e.g., visit to the emergency room). In addition, the following individuals may know your child participated in research:


(If applicable for documenting study participation and research results in electronic health record)

The study team may be notified if your child receives other health care services at URMC or its Affiliates (e.g., visit to the emergency room). In addition, the following individuals may know your child participated in research and may see results of testing conducted for this study:


Benefits of Participation

Choose or modify ONE of the following groups of sentences as appropriate to the specific study:

Your child will not benefit from being in this research study.

- OR -

Your child might not benefit from being in this research study. The potential benefit to your child from being in this study might be…List any direct benefits to the subject that might reasonably be expected from the research.


**Payment to subjects for participation is not considered a benefit, it is an incentive. Payment information can be provided in the payment section below.**


New Study Findings (If applicable)

If we discover anything that might make you change your mind about continuing in the study, we will let you know.


Alternatives to Participation (If applicable)

For biomedical research, use this section to discuss appropriate procedures or courses of treatment, if any, that might be advantageous to the subject (e.g., standard treatment, no treatment, comfort care or participation in another study). For other types of research, use this section to discuss appropriate procedures or options, if any, that might be advantageous to the subject (e.g., not participating or alternative options).


If the study is minimal risk and the only alternative is to not to participate this section is not necessary and should be deleted.


Sponsor Support

The University of Rochester is receiving funds from [insert sponsor name] to conduct this study.


The RSRB requires that all consent forms disclose which agencies or institutions (e.g., National Institutes of Health, Department of Defense, Center for Disease Control, State agencies, foundations or industry sponsors) are funding the research.


If the study is not funded by an external agency (i.e. departmental funds) this section may be deleted.


Financial Disclosure Statement (if applicable)

If the Principal Investigator or any other study personnel have a conflict of interest management plan involving the study sponsor and the plan requires disclosure of the conflict in the consent form, insert disclosure statement here.


Costs

Choose or modify ONE of the following sentences as appropriate to the specific study:

There will be no cost to you/your child to participate in this study.

- OR -

Some of the tests/procedures/exams [specify what tests/procedures/exams] your child will receive are standard care. You and/or your child’s insurance company will be responsible for paying for any tests/procedures/exams that are done as part of standard care. You are encouraged to discuss your coverage with your child’s insurance provider.


If medications, tests and therapies are to be provided free as part of the study, please specify.


Payments

Choose ONE of the following options, plus additional applicable language, as appropriate to the specific study:

You/Your child will not be paid for participating in this study.

- OR -

You/Your child will be paid $XX for taking part in this study. Specify who will be paid for participation (the parent or the child). If parents and children will each receive payment, list each individually. 

If subjects are to be paid for participation, specify the amount, schedule of payment and conditions for payment (e.g., You/your child will receive $100.00 for each completed study visit.  You/your child will not be paid for visits that your child does not complete. You/Your child will be paid up to a total of $1200.00.).  When applicable, payments should be based on a prorated system.


(If applicable) Payment received for participation in research is considered taxable income.  If you receive payment for your child’s participation in studies at the University of Rochester and its affiliates that exceeds $600.00 in any one calendar year, the University is required to report this information to the Internal Revenue Service (IRS) in a 1099 (Miscellaneous Income) form.  You will be sent a copy of this form and a copy will be sent to the IRS.


(If applicable) You/Your child will not receive any money that may result from any commercial tests or products that are developed as a result of this study.


Reimbursement for Travel Expenses (If applicable)

Include language regarding reimbursement for travel expenses, such as plane, taxi, hotel, mileage costs, and modify as applicable to the study:

You will be reimbursed for reasonable out of pocket expenses after submission of receipts to the study team.  You will only be reimbursed for actual expenses up to a maximum amount of $XX.  Such reimbursed expenses are not taxable.


Circumstances for Dismissal (If applicable)

List the circumstances, if any, under which the subject’s participation may be stopped without their consent (e.g., “Your child may be withdrawn from the study if they do not keep appointments for study visits or if they cannot complete study activities.” OR “Your child may be withdrawn from the study if their disease becomes worse or if your child’s doctor feels that staying in the study is harmful to their health.”)


Early Termination (If applicable)

List any consequences for subject self-withdrawal (e.g., adverse health/welfare effects) and procedures for orderly termination of participation (e.g., “To ensure your child’s safety after they have stopped the study drug, your child will be asked to return approximately 2 weeks after their last dose to complete a physical and neurological exam.”


Compensation for Injury (For greater than minimal risk studies only; this section may be omitted if the study involves no more than minimal risk.)

If you are directly injured by the [drug(s) / device(s)] being studied, or by medical procedures needed because of this study, and you receive medical care for the injury, you may need to pay for that care. You will be reimbursed for reasonable and necessary medical costs for such care, but you might not be reimbursed for care covered and paid for by a third party like your health insurance provider, or costs such as required co-payments or deductibles related to that coverage. No other funds have been set aside to pay for such things as lost wages or expenses due to a current underlying illness or condition.


If your research injury is paid for by the University [or Sponsor], we will collect your name, date of birth, gender, and Medicare Health Insurance Claim Number or Social Security Number to determine your Medicare status. This information will be used only in accordance with the law. If you are a Medicare beneficiary, information about the study you are in, and any payments made related to your injury, will be reported to the Centers for Medicare & Medicaid Services (CMS), in accordance with CMS requirements. This information will not be used for any other purpose.

- OR –

For non-biomedical research: The University does not provide any payment for problems that could result from your participation in the study.


Confidentiality of Records (For studies with which no protected health information (PHI) is being collected or if you are not part of the covered entity)

The University of Rochester makes every effort to keep the information collected from your child private. In order to do so, we will [insert protection measures]. Sometimes, however, researchers need to share information that may identify you/your child with people that work for the University, the government or the study sponsor. If this does happen we will take precautions to protect the information your child has provided. Results of the research may be presented at meetings or in publications, but your name will not be used.


Confidentiality of Records and Authorization to Use and Disclose Information for Research Purposes (For studies with which protected health information (PHI) is being collected)

The University of Rochester makes every effort to keep the information collected from your child private. In order to do so, we will [insert protection measures]. Sometimes, however, researchers need to share information that may identify your child with people that work for the University, regulators or the study sponsor.

If you have never received a copy of the University of Rochester Medical Center (URMC) and Affiliates Notice of Privacy Practices, please ask the investigator for one. [Note to Investigators: the Notice must be provided and receipt documented if this is the first contact with URMC and Affiliates (copies available on web).]


What information may be used and given to others?

The study doctor will get your child’s personal and medical information. For example:


Who may use and give out information about your child?


Your child’s information may be given to:


Why will this information be used and/or given to others?


If the results of this study are made public, information that identifies your child will not be used.


What if I decide not to give permission to use and give out my child’s health information?

Then your child will not be able to be in this research study.



May I review or copy my child’s information?

Yes, but only after the research is over.


How long will this be permission be valid?

This permission will last indefinitely. [If you will destroy the records at a definite point that should be stated instead and should be consistent with what is listed in both your protocol and application.]


May I cancel my permission to use and disclose information?

Yes. You may cancel your permission to use and disclose your child’s health information at any time. You do this by sending written notice to the study doctor. Upon receiving the written notice, the study team will no longer use or disclose your child’s health information and they will not be able to stay in this study. Information that has already been gathered may need to be used and given to others for the validity of the study.


May I withdraw from the study?

Yes. If you withdraw your permission to be in the study, no new health information identifying your child will be gathered after that date. Information that has already been gathered may still be used and given to others.


Is my child’s health information protected after it has been given to others?

No. There is a risk that your child’s information will be given to others without your permission.


Certificate of Confidentiality (If applicable)

Note: Certificates of Confidentiality are issued by the National Institutes of Health (NIH) and other Department of Health and Human Services (DHHS) agencies to protect identifiable research information from forced disclosure. They may be granted for studies collecting information that, if disclosed, could have adverse consequences for subjects or damage their financial standing, employability, insurability, or reputation. Certificates can be applied to biomedical, behavioral, clinical or other research. Certificates can be issued for non-federally funded research if the research poses the same involuntary disclosure concerns.


For studies that have a federal Certificate of Confidentiality: Insert language provided by the federal agency that issued the certificate or insert the RSRB language below.


To help us further protect your privacy, the investigators have obtained a Confidentiality Certificate from the Department of Health and Human Services (DHHS).


With this Certificate, the investigators cannot be forced (for example, by court subpoena) to disclose research information that may identify you in any Federal, State, or local civil, criminal, administrative, legislative, or other proceedings. Disclosure will be necessary, however, upon request of DHHS for audit or program evaluation purposes.


You should understand that a Confidentiality Certificate does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. If an insurer, employer, or other person obtains your consent to receive research information, then the investigator may not use the Certificate to withhold that information. This means that you and your family must also actively protect your own privacy.


Finally, you should understand that the investigator is not prevented from taking steps, including reporting to authorities, to prevent serious harm to yourself or others. Include the following only if applicable: The Certificate of Confidentiality will not be used to prevent disclosure to state or local authorities of child abuse and neglect, or serious harm to the subject or others.


Contact Persons

For more information concerning this research or if you feel that your child’s participation has resulted in any research related injury, emotional or physical discomfort please contact: [insert contact person’s name (for research related injury contact person must be a clinician)] at [telephone number]


Please contact the University of Rochester Research Subjects Review Board at 265 Crittenden Blvd., CU 420628, Rochester, NY 14642, Telephone (585) 276-0005 or (877) 449-4441 [insert country code (001) if applicable] for the following reasons:


If there are additional informational sources related to the study (e.g., client representatives, subject advocate or individuals at other study sites as appropriate), list here with contact information.


Voluntary Participation

Taking part in this study is voluntary. Your child is free not to take part or to withdraw at any time, for whatever reason. No matter what decision you and your child make, there will be no penalty or loss of benefit to which you and your child are entitled. In the event that your child withdraws or you withdraw your child from this study, the information your child has already provided will be kept in a confidential manner.


Additional student-subject wording [delete if not applicable]: If you do not wish to take part, nothing bad will happen to you or your child. Saying no will not affect anything at school for your child.


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Insert any checkbox options for future use of biological specimens or research data, future contact, audio/video recording, etc. If possible, checkbox options & signature blocks should appear all on one page.

Signature/Dates

After reading and discussing the information in this permission form you should understand:

Parent Permission

I have read (or have had read to me) the contents of this permission form and have been encouraged to ask questions. I have received answers to my questions. I agree to allow my child to participate in this study. I have received (or will receive) a copy of this form for my records and future reference.


Subject Name (Printed by Parent)


Parent Name (Printed by Parent)


Signature of Parent Date


Person Obtaining Permission

I have read this form to the parent and/or the parent has read this form. I will provide the parent with a signed copy of this permission form. An explanation of the research was given and questions from the parent were solicited and answered to the parent’s satisfaction. In my judgment, the parent has demonstrated comprehension of the information.  I have given the parent adequate opportunity to read the permission form before signing.


Name and Title (Print)


Signature of Person Obtaining Permission Date

RSRB Case Number: 000XXXX Page 12 of 12 Version Date: xx/xx/20xx



OSATS – [INSERT TITLE HERE] TRAINEE NAME
(SAMPLE) POLICY ON THE RECRUITMENT OF EXOFFENDERS [INSERT YOUR
02032 CHAPTER [INSERT] PAGE 2 02 DEPARTMENT OF PROFESSIONAL


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