ࡱ> CEB -bjbj .. V[[[[[ooo8<o8L^(}N "Q[!!![[!R[[}!}xC osvi0r#`r#r#[z(mI!!!!r# !: ATTACHMENT C SAMPLE CONSENT FORM * (Applicant will modify this form by providing all information relevant to the proposal and deleting material that is not relevant. For instance, this paragraph and the explanatory notes in the form fields should be deleted.) I hereby give my consent for my participation in the project entitled: ________________________. I understand that the person responsible for this project is _________, telephone number, ___________. ___________ has explained that these studies are part of a project that has the following objectives:  FORMTEXT   (Applicant should briefly list objectives.)     FORMTEXT   (applicant s name)     or  FORMTEXT  (applicant s name)      authorized representative has (1) explained the procedures to be followed and identified those that are experimental, (2) described the attendant discomforts and risks, and (3) described the appropriate alternative procedures.  FORMTEXT Applicant should provide adequate explanation and description of these things on the consent form. Information concerning payment for my participation in this study has been explained to me as follows:  FORMTEXT Applicant should include the estimated amount of payment for project completion, the method of disbursement, the schedule of payment, and the effect of my withdrawal from participation. The risks have been explained to me as follows:  FORMTEXT (Applicant should list all risks of more than negligible probability and/or severity.)  It has further been explained to me that the total duration of my participation will be FORMTEXT      , that only  FORMTEXT       will have access to the records and/or data collection for this study, and that all data associated with this study will remain strictly confidential. Dr.  FORMTEXT    (faculty)    has agreed to answer any inquiries I may have concerning the procedures and has informed me that I may contact the ˾ Human Subject Review Committee by writing to: Chair, Human Subjects Review Committee, c/o Office of the Provost, ˾, 3410 Taft Blvd., Wichita Falls, TX 76308, or by calling the Provost at (940) 397-4226. If this research project causes any physical injury to participants in this project, treatment is not necessarily available at ˾ Student Health Center, nor is there necessarily any insurance carried by the University or its personnel to cover such an injury. Financial compensation for any such injury must be provided through the participants own insurance program. Further information about these matters may be obtained from Chair, Human Subjects Review Committee, c/o Office of the Provost, ˾, 3410 Taft Blvd., Wichita Falls, TX 76308. I understand that I may not derive therapeutic treatment from participation in this study. I understand that I may discontinue my participation in this study at any time without penalty. Signature of Subject _____________________________________________ Date ___________________ Signature of Parent/Guardian or Authorized Representative (if required) ______________________________________________________________ Date ___________________ Signature of Witness to Oral Presentation ______________________________________________________________ Date ___________________ * ALL BLANK   !#&01<cps   M O ʸ聯vgYK=h[5CCJOJQJ^JaJh[CJOJQJ^JaJh4sCJOJQJ^JaJhJl6CJOJQJ^JaJhu6CJOJQJ^JaJ#h?Dh[6CJOJQJ^JaJh4s6CJOJQJ^JaJ#h[h[5CJOJQJ^JaJ#h[h[>*CJOJQJ^JaJ&h4sh[6>*CJOJQJ^JaJ h[hShCJOJQJ^JaJ h[h[CJOJQJ^JaJ %&  i j # $ TU~XYmndgditdgd[gdk$a$gd[O h i j p r Ⱥ֫ȋs[I[ȝ#h?Dhit6CJOJQJ^JaJ.jhitCJOJQJU^JaJmHnHu/jhith CJOJQJU^JaJ#jhitCJOJQJU^JaJh?DCJOJQJ^JaJhs6CJOJQJ^JaJhsCJOJQJ^JaJh[CJOJQJ^JaJh[5CCJOJQJ^JaJhitCJOJQJ^JaJhs$CJOJQJ^JaJ   6 : @ B D J L ` b d f A ߁i߁ZI h?Dh[CJOJQJ^JaJh?D6CJOJQJ^JaJ/jh?Dh CJOJQJU^JaJh[CJOJQJ^JaJhitCJOJQJ^JaJ#h?Dhit6CJOJQJ^JaJ.jh?DCJOJQJU^JaJmHnHu/jvh?Dh CJOJQJU^JaJh?DCJOJQJ^JaJ#jh?DCJOJQJU^JaJA B t  # $ Ϳ}oaS<*#hith?D6CJOJQJ^JaJ,jhith?D6CJOJQJU^JaJh?DCJOJQJ^JaJhA|CJOJQJ^JaJhuCJOJQJ^JaJ.hithit6CJOJQJ^JaJmHnHu/jbhith CJOJQJU^JaJ#jhitCJOJQJU^JaJhitCJOJQJ^JaJ h?DhA|CJOJQJ^JaJ h?Dh[CJOJQJ^JaJ h?Dh?DCJOJQJ^JaJ QRSTUCDNϷϥwewMe7ewew+h4sh4sCJOJQJ^JaJmHnHu/jNhA|h% CJOJQJU^JaJ#jhA|CJOJQJU^JaJhA|CJOJQJ^JaJh?DCJOJQJ^JaJ#h?Dhit6CJOJQJ^JaJ#hithit6CJOJQJ^JaJ.hithit6CJOJQJ^JaJmHnHu,jhith?D6CJOJQJU^JaJ2jhith 6CJOJQJU^JaJNO  $&:<>HJUpWXսկկսկկսqկ`qRRhlH CJOJQJ^JaJ hA|hA|CJOJQJ^JaJh4sCJOJQJ^JaJ/jhA|h% CJOJQJU^JaJ/j:hA|h% CJOJQJU^JaJhA|CJOJQJ^JaJ.jhA|CJOJQJU^JaJmHnHu#jhA|CJOJQJU^JaJ/jhA|h% CJOJQJU^JaJ,,,,,,,,,,,,,,,,,,,,,,----ᓂzvzvzvzvrhbhWhbrvhs$0JmHnHu hk0Jjhk0JUhkh1*Ajh1*AU h[h[CJOJQJ^JaJh[CJOJQJ^JaJh]uCJOJQJ^JaJh4s5CJOJQJ^JaJU#h]uhlH 5CJOJQJ^JaJh]u5CJOJQJ^JaJhlH CJOJQJ^JaJ hlH hlH CJOJQJ^JaJkl,,,,,,,,,,,,,,----dgd[FORM FIELDS MUST BE COMPLETED with the specifics of the research project. 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Arial BlackA BCambria Math"h((  24 3QHP ?[2!xx ATTACHMENT C Robert RedmonValued MSU CustomerOh+'0 $ D P \hpxATTACHMENT CRobert RedmonNormalValued ˾ Customer3Microsoft Office Word@G@l@0 ՜.+,0  hp  ˾   ATTACHMENT C Title !"#$%&'()*+,-./013456789;<=>?@ADRoot Entry FQ FData 1Table r#WordDocument..SummaryInformation(2DocumentSummaryInformation8:CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q