ࡱ> PSO 8bjbjvv 4&FF4h'<c$fkmmmmmm,Z "\4kk 4Ƀ;W0h"h"h"F Q:   Ƶ Division of Research & Federal Relations CONSENT FORM FOR RESEARCH PARTICIPANTS Part I: Section I. Investigator Name: Click here to enter text. Department: Click here to enter text. Address: Click here to enter text. City, State, Zip Code: Click here to enter text. Telephone Number: Click here to enter text. JSU Email Address: Click here to enter text. Section II: Advisor (if submitting student application) Name: Click here to enter text. Your advisor: Click here to enter text. Department: Click here to enter text. Address: Click here to enter text. City, State, Zip Code: Click here to enter text. Telephone Number: Click here to enter text. JSU Email Address: Click here to enter text. Part II: Project Information You are being asked to take part in a research study to determine Click here to enter text. The goal of the research project is to determine the relationship (if any) between certain Click here to enter text. And Click here to enter text. METHODS AND PROCEDURES: The entire procedure should take Click here to enter text. If you agree to take part, Click here to enter text. You will first be asked several questions about personal and background information such as your age; race, education level, etc. Click here to enter text. The Click here to enter text. measures only an estimate of Click here to enter text.; therefore, results will not be provided to you. You will then be read Click here to enter text. A (story, explanation, etc.) about the research subject and asked to answer several questions based on the information you are given. Finally, you will be asked to complete two brief self-report forms. You may ask questions at any time during the study and you are free to contact my advisor or me should you have any questions about the research project. RISKS AND DISCOMFORTS: We expect no risks or discomfort for people in this study. However, it is possible that you may feel somewhat uneasy answering the questions involved. BENEFITS: The information obtained in this study may not directly benefit you. However, the results may provide needed information about Click here to enter text. CONFIDENTIALITY OF RECORDS: All information obtained during this study is private. That is, we protect the privacy of people by withholding their names and other personal information from all persons not connected to this study. Each person will be identified using a code number rather than your name. The raw data shall be retained for 3 years, and all records relating to this research shall be retained for 3 years after completion of the research. All records shall be accessible for inspection and copying by authorized representatives of the Institutional Review Board at reasonable times and in a reasonable manner. Information will be stored in the most secure manner for 3 years as required by federal law. Although the information in this study is private, security of the data can only be promised within the boundaries of the university and researcher or faculty advisor. Confidentiality will be broken if the information obtained reveals that you intend to harm yourself or another person. VOLUNTARY PARTICIPATION: Taking part in this study is completely voluntary. You may refuse to answer any specific question. Participants may withdraw at any time without penalty or prejudice. PARTICIPATION CONSENT: I have had the purposes and procedures of this study explained to me and have had the opportunity to ask questions. My signature shows my willingness to take part in the study under the conditions stated. This study has been reviewed by the Institutional Review Board of Ƶ, which ensures that research projects involving human subjects follow federal regulations. Any questions or concerns about rights as a research participant should be directed to Vice President for Research and Federal Relations, Ƶ, P.O. Box 17057, Jackson, Mississippi, 39217, or (601) 979-2931. _________________________________ __________ Participant Signature Date __________________________________ __________ Investigator Signature Date Sample of HIPAA paragraph to include on consent for studies using protected health information. Do not include if you are not conducting a clinical or medical study. Protected Health Information: Protected health information is any personal information that relates to your past, present, or future health or physical condition through which you can be identified. The data collection in this study includes such things as age, race, physical health status, and emotional adjustment. Study information collected solely for this research study and not as part of your regular care will not be included in your medical record. A decision to participate in this research means that you agree to the use of your health information for the study described in this form. This information will not be released beyond the purposes of conducting this study. The information collected for this study will be kept for a period of three years. If you decide to withdraw, the information already collected about you may still be used in this study. 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