Search Department of Developmental Services Filtered Topic Search
Office of the Commissioner IRB
Sample Format for "Informed Consent Form"
NOTE: An "Informed Consent Form" must be included with your application for the use of human subjects in research. Below is a sample of the format that you should adapt to your specific requirements. Please follow the guidelines for informed consent as set forth in 45 C.F.R. ยง 46.116.

*** Begin Sample ***

I hereby consent to my participation in the following research project:

(Title of Project)
(Project Director)
(Department/Agency)
(Address)
(Telephone) (Fax) (E-mail)
(Sponsor)

State the purpose of the research in lay terms, the procedures to be followed and their purposes, including any which are experimental

  • Describe anything that may cause embarrassment or discomfort to the participants.
  • Describe any benefits to be expected from the project to the participants or society in general.
  • Describe any alternative procedures (if appropriate) which may be available.
  • Provide the name(s) and the telephone number(s) of the individual(s) who would be prepared to answer questions concerning the project.
  • State that the participant is free to withdraw consent and to discontinue participation in the project at any time, without prejudice.
Signature of Subject (including children over 7 years of age)

Signature of Parent or Guardian (if subject is under 18 years of age)

Signature of Person Obtaining Consent

Date

Date

Date
*** End Sample ***