(Include or exclude information as applicable.)

                (Item #s are keyed to the checklist for reference only-do not include in your consent.)

                INDIANA UNIVERSITY - BLOOMINGTON

                INFORMED CONSENT STATEMENT

                [List title of project here]

 You are invited to participate in a research study. The purpose of this study is _________.

 INFORMATION

 Describe all procedures, preferably in chronological order, which will be employed in the study.  Point out any that are considered experimental and explain technical and medical terminology.

 State the amount of time required of the subject per session and for the total duration of the study.

 If applicable to your study, describe:

 Alternative procedures or courses of treatment [when experimental procedures are being used].

 The number of subjects that will be participating in the research.

 Information concerning taping or filming.

 A disclaimer for the use of deception.

 RISKS

 List the foreseeable risks or discomforts, if any, of each of the procedures to be used in the study, and any measures which will be used to minimize the risks.

EMERGENCY MEDICAL TREATMENT

In the unlikely event of physical injury resulting from your participation in this research, emergency medical treatment will be provided at no cost to you.  Be certain that you immediately notify the researcher if you are injured.  If you require additional medical treatment you will be responsible for the cost.  No other compensation will be provided if you are injured in this research.

BENEFITS

List the benefits you anticipate will be achieved from this research, either to the subjects, others, or the body of knowledge.

CONFIDENTIALITY

The information in the study records will be kept confidential.  Data will be stored securely and will be made available only to persons conducting the study unless you specifically give permission in writing to do otherwise.  No reference will be made in oral or written reports which could link you to the study.

COMPENSATION (if applicable add here)

For participating in this study you will receive _____________________.  Other ways to earn the same amount of credit are _______________________.  If you withdraw from the study prior to its completion, you will receive _____________________________

__________

subject's initials

CONTACT

If you have questions at any time about the study or the procedures, (or you experience adverse effects as a result of participating in this study,*) you may contact the researcher,   [name]  , at   [address]  , and  [phone number]  .  If you feel you have not been treated according to the descriptions in this form, or your rights as a participant in research have been violated during the course of this project, you may contact the office for the Human Subjects Committee, Bryan Hall 10, Indiana University, Bloomington, IN 47405, 812/855-3067. 

PARTICIPATION

Your participation in this study is voluntary; you may decline to participate without penalty.  If you decide to participate, you may withdraw from the study at any time without penalty and without loss of benefits to which you are otherwise entitled.  If you withdraw from the study before data collection is completed your data will be returned to you or destroyed.

CONSENT

I have read and understand the above information.  I have received a copy of this form.  I agree to participate in this study.

Subject's signature_____________________________________ Date _________________

Investigator's signature__________________________________ Date _________________