ࡱ> z|y 'bjbj p"gp"gPPPPP$tttP<t.p<<<'.).).).).).).$R03LM.P@M.PPpb.   FPP'. '.  n'*+ /+ .x.0.O+hT36T3@+T3P+D<P ^ jS<<<M.M.D<<<.T3<<<<<<<<<X : MARQUETTE UNIVERSITY PARENT PERMISSION FORM (insert title of project) (insert Principal Investigators name) (insert Academic Department) Your child has been invited to participate in this research study. Before you agree to allow your child to participate, it is important that you read and understand the following information. Participation is completely voluntary. Please ask questions about anything you do not understand before deciding whether or not to give permission for your child to participate. PURPOSE: The purpose of this research study is (This should be a short, concise, statement that can be clearly understood by individuals with no knowledge of the researchers field avoid all jargon.) Your child will be one of approximately X participants in this research study. PROCEDURES: (This should be a step-by-step account of procedures as observed/experienced by the child participant. For audio or video taping, include a statement such as Your child will be audio taped during the interview portion of the study to ensure accuracy. The tapes will later be transcribed and destroyed after X years beyond the completion of the study. For confidentiality purposes, your childs name will not be recorded.) DURATION: Your childs participation will consist of (This should inform the parent of the number of sessions, minutes, hours, days, etc. that their child will be actively engaged in the research.) RISKS: The risks associated with participation in this study include (No study is without risk. If the risks are minimal, please state that the risks are no more than the child would encounter in everyday life. If there are identifiable risks, list the risks and describe the safeguards in place to avoid these risks. Depending on the type of research you are conducting, you may become privy to information that triggers the mandatory reporting requirements for child abuse, child neglect, elder abuse or intent to harm self or others. In these types of research, this must be disclosed as a risk to participants.) BENEFITS: The benefits associated with participation in this study include (Benefits refer to direct benefits. Research sometimes provides subjects with treatment, diagnosis or examination for an illness or condition. In these cases the research involves evaluations that may benefit the subjects by improving their condition or provide a better understanding of their condition. Investigators should clearly detail these potential benefits in the consent form, while not overstating these benefits. Additionally, benefits cannot be guaranteed. Not every study has direct benefits to subjects. If the study does not have direct benefits to subjects, state this. You can also include a statement that participation may help provide a better understanding of the topic you are researching.) CONFIDENTIALITY: All information your child reveals in this study will be kept confidential. All your childs data will be assigned an arbitrary code number rather than using your childs name or other information that could identify your child as an individual. When the results of the study are published, your child will not be identified by name. The data will be destroyed by shredding paper documents and deleting electronic files (number of years or months etc.) after the completion of the study. (A statement describing procedures taken to protect the privacy and confidentiality of the child participant. Describe how, where, and for how long data will be stored plus how the data will be disposed of and any anticipated use of the data in the future. In addition, describe how tapes (if used) will be maintained and when they will be erased. Also, discuss the limits of the confidentiality. For example, if focus groups are used, you cannot assure that other participants will maintain the subjects confidentiality and privacy (such as All focus group participants are instructed to keep discussions confidential. However, the researcher(s) cannot guarantee that all focus group participants will respect everyones confidentiality.). For research that is regulated by the Food and Drug Administration, please include a statement that indicates the research records may be inspected by the Food and Drug Administration.) Your childs research records may be inspected by the Ӱ Institutional Review Board or its designees, (insert study sponsor if sponsored by a funding agency, and the FDA for research regulated by the FDA) and (as allowable by law) state and federal agencies. COMPENSATION: (Delete this section if not applicable. If applicable, describe the amount of compensation, how and when it will be distributed, and in what form. The key issue the IRB will evaluate is the potential for compensation to be coercive. If pro-rated payments will be paid to subjects for early withdrawal or another purpose, that information needs to be clearly stated.) Extra Costs to Participate: (Research sometimes requires subjects to pay out of their pocket for certain aspects of the research study. This can include, but is not limited to, transportation costs to and from the study site, costs related to medicines or other treatments, costs of study related supplies, etc. If there are no extra costs to subjects, delete this section.) Injury or Illness: (This section is not required unless this project involves more than minimal risk.) Ӱ will not provide medical treatment or financial compensation if your child is injured or becomes ill as a result of participating in this research project. This does not waive any legal rights nor release any claim based on negligence. Voluntary Nature of Participation: Your childs participation in this study is completely voluntary and your child may withdraw from the study and stop participating at any time without penalty or loss of benefits to which your child is otherwise entitled. (Indicate the procedure for a participant to withdraw his/her data. Although participants should be able to withdraw their participation at any time, situations do occur during the research process making that difficult or even impossible. For example, if at some point during the research project the data will be de-identified, it may not be reasonable to find and extract a particular persons data from the data set. In this section, also indicate what will happen to the data if participants withdraw.) Contact Information: If you have any questions about this research project, you can contact (insert PI name and contact information, plus the name and contact information for any additional research personnel that also serve as a contact for participants.) If you have questions or concerns about your childs rights as a research participant, you can contact Ӱs Office of Research Compliance at (414) 288-7570. I HAVE HAD THE OPPORTUNITY TO READ THIS PARENT PERMISSION FORM, ASK QUESTIONS ABOUT THE RESEARCH PROJECT AND AM PREPARED TO GIVE MY PERMISSION FOR MY CHILD TO PARTICIPATE IN THIS PROJECT. ____________________________________________ __________________________ Parents Signature(s) Date ____________________________________________ Parents Name(s) ____________________________________________ _________________________ Researchers Signature Date      Initials: __________ Page  PAGE 2 of  NUMPAGES 3 Date: __________  Initials: __________ Page  PAGE 1 of  NUMPAGES 3 Date: __________ Page  PAGE 3 of  NUMPAGES 3 &'*+,Fm  1   ' Ƚ{s{d{s{{{Uh\hVf0J5>*CJ\h\hVfB*CJaJphfhuwCJaJh\hVfCJaJh\hVf5CJaJh\hVf0J5>*CJaJhCJaJhKaCJaJholh_CJaJholh-HCJaJholh-HB*CJaJphfholh-HCJaJholh"*CJaJhKaCJaJholh_CJaJ!,Fm     '(abF$a$gdVfgd\$a$gdol$a$gdol$a$gdM ]' ( ) } ! ) a p HN  V#'(789:IMhKaCJaJhuwCJaJh\hVf0J5>*CJ\huwB*CJaJphfhB*CJaJphfh\hVfB*CJaJphfh\hVfCJaJh\hVf5CJaJ@MTZ[.]ah"~GHD핉~holhVfCJaJhD:hVf5CJaJh\hVf0J5>*CJ\huwB*CJaJphfhB*CJaJphfh\hVfB*CJaJphf#h\hVfB*CJ\]aJphfhCJaJhuwCJaJh\hVfCJaJhKaCJaJ-`ab|}~BFGhiky'+4J !H!L!M!`!峥{{{{{hKaCJaJhuwCJaJh\hVfB*CJaJphfh\hVfCJaJh\hVf5;CJaJ h\hVf0J5;>*䴳:մ5;C$\մ05;>*䴳aմ䴳:մ*䴳f.!!"""##$$$$$$<%%%%%%%%%%% $ !a$gdol $ !a$gdolgd\`!a!e!h!!!!"M"Q"c"d"g"v"z"{""""""""#&#7#z########$$ $$$#$/$2$$$$$$$$$$%%"%<%%%议holhUCJaJholh#&CJaJhCJaJholh-HCJaJhS6CJaJhKaCJaJh\"CJaJh\hVfB*CJaJphfhSCJaJh\hVfCJaJh\hVf5CJaJ8%%%%%%%%%%%%%%%%%%%&&&&"&#&$&%&)&*&4&5&6&7&x&y&z&{&|&}&&&'B'G'H'N'O'P'Q'{h8huwCJaJh;$CJaJmHnHujhuwCJUaJjhsyhuwCJUaJhsyhuwCJaJhuwCJaJhuwh\"huwCJaJjhSUmHnHuhjhUholhCJaJholh-HCJaJ0%%&y&z&|&}&'u'v''''' $ !a$gdol$ , xa$gd\" $  a$gdsy$ , xa$gd'   gd\"$ , xa$gd\" Q'U'V'`'a'b'c'd'u'v'{'|'''''''''''''''ź溶holhCJaJhhuwh8huwCJaJhuwCJaJh;$CJaJmHnHujhuwCJUaJjhsyhuwCJUaJhsyhuwCJaJ6&P1h:pS/ =!"#$% 9 0&P1h:p\"/ =!"#$% F_nV)A+$ 3[JFIFC      C  4" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?(((((((8ހ k~?ں_ ZƃRj'Y 1Ͻ7^}xAwōp [Am,fE5`:*N㝭z0ʕ:ъm_Cve~f"9Ğu爼9g}v6]-  @ぃؑ|Ta?\k5KSWKg|5 F +T0*|;Aq?NPklUVy\J7~o wk\ѿc;{NGg Yio]ſ)~؆>\h$FUG v g2Fضֿ&|n/ 6bA+Rf=5.< |Q3B$+PTh-I8tH0# :[cR^ϻO;zєV-QM=iUNk6E ۗ4PEPEPEPEPEPEPEPEPEPEPEPEPEPEPSzH+*JuwM?QY x<Qoqgwkq$M/?ZAoYt6jk.RAeGV7Z#୿H?rmOȵ5x"D<% ڒ^ŲBeMѮ^k҉`ܨE | |*B[{+QRm mg4qLU e=kٓ޾[XiockCtF\0cuS N~g UBT*y/ͿO33VJ^Vz x[Xw|?G)1-rt]J$RگbIxw>*."8':u%R\ ^g{Mtljnv.%~}-n˺[/^׃aZ&k8/f*fe0CBJ.Ac~9Ëψ_ލvs~-`xTd홒 FX&#TѾ ~kךLj5 Ev uqo+,Xvb30|mxV«O&aq1i ˞ LƵ,[R济3M&QjVImgfRtSlѻV>9jm-}a} /|Hٯx;n{x^PLF!5;s郟0s_Fƿ6qСC#0xv8:E:?=QE ( ( ( ( ( ( ( ( ( ( ( ( (>d3e?٪nkq3e?٪jkxOx9H'6Y𝥅ֱ j~Ӯ.nZt%fij`vpud5;[S5t+$32a#ǠF(O^y CLuῌ/eFv}ё0>bN6 G!&i?ᶽҼAzylD5mqڌJq?xat:I)Ye'ꏲ=HMOKk&wyĺ}-⻋;q#eHlYX(;y8}LVDkn`P#fr3c9N?Ec_'{_?pnWR)GȮU(~&=,:F5QRt9͜/{_405> t!,?&<{x]:Om[2B:\ Ok_Zm7Z?+GSӦ%o&hx;f,e$g _e4~QNQNAEP0(((((((((((((O(?]3M1Ʒy]B58Golk9?F z/G_䏺7>"揢jQ'U IeccwFNA>XG:.GxV!k(I H c?k`Sm_)eTdӏ}Ohb^M^_ (Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@2Golk9֯?F(?]3M1?F z/͞kG??hmZl_gyIIPHf;|M.|9xJ!{%&h8ϰ*sIT5Poi7uIy\<\_o]>눸9a+K8GufwguĬ}OW*T6_Щ ][ x^!$Ry!LL3n Q_ _p>-5&"heW/,4#b6rX5ֵܶ Sm}w6p퐬ve~w'&ȁ?U"i~񷛮jV/mRt wnߺTI!u K~ G9֔,67>^mZoY]k9nVN-Z沽Oѿ[zΙ$޳xwI֕&5խK!1V*f@s `χ)! 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