ࡱ> a wbjbjrr L\L\3XXXXXlll8\$l@$ $(%%%N+N+N+???????$BlE?XN+**|N+N+?XX%%~@---N+FX%X%?-N+?--;<%P+^;?@0@;E+E(<<hEX<N+N+-N+N+N+N+N+??-N+N+N+@N+N+N+N+EN+N+N+N+N+N+N+N+N+> :  IRBF010d RESEARCH WITH MINORS COMBINED INFORMED CONSENT (Combined Parental Consent and Child Assent form for Minors over 12 years) General Information Use this form for requesting parental consent for enrolling their child who is over 12 years of age This template is expected to allow the investigating team to obtain signatures from both the parent as well as the child on the same form When separate child assent is needed from minors who are 12 years and older, use IRBF010e and IRBF010f. This template is suitable for studies that qualify for exemption and those which are reviewed by the expedited or full review mechanisms. Alterations and waiver of this template are strongly discouraged Use the same text when requesting online consent from the parents. However, child assent must not be administered online. Instructions This form contains two major sections and a third signature section: Parental Permission section signed by the researcher and given to the parent Child Assent Template signed by the researcher and given to the child The signature section has to be co-signed by the parent and his/her child as below: The parent can sign the copy at home for all educational research studies unless specified by the IRB. The researcher must be available to answer questions. The child cannot sign the copy at home. The child assent has to be obtained by the researcher. This section will be retained by the researcher Barring the actual signatures, the text boxes in three sections must be properly completed before submitting for IRB approval. Related IRB Forms: Form IDDescriptionIRB CommentAppendix BThis form has to be completed to specifically describe the interventions when researching with minorsMandatory when enrolling minorsIRBF010aParental consent for enrolling minors within the age 0 to 12 Use either IRBF010b or IRBF010c as child assentMust be obtained before administering child assentIRBF010bChild assent for children less than 7 yearsNo signature is necessaryIRBF010cChild Assent for minors 7-12 yearsSignature may be waivedIRBF0101dTHIS FORMMandatory signaturesIRBF010eParental Consent for minors 12+ yearsIn most cases signature is required before enrolling the childIRBF010fChild Assent for minors 12+ yearsChildren must sign or give oral consent  PARENTAL PERMISSION (Parents Copy) Primary Investigator(s) FORMTEXT       Student  FORMCHECKBOX Contact information  FORMTEXT MTSU Office (If applicable), Telephone and Email IDDepartment Institution FORMTEXT      Faculty Advisor FORMTEXT      Department FORMTEXT      Study Title FORMTEXT      IRB IDNOT APPROVEDExpirationNOT APPROVED Child s Name (Age 12+) (type or print)  FORMTEXT        The following information is provided to you because your child may qualify to participate in the above identified research study. Please read this disclosure document carefully and feel free to ask any questions before you agree to enroll your child. The researcher must adequately answer all of your questions before your child can be enrolled. The researcher MUST NOT enroll your child without an active consent from you. Also, a copy of this consent document, duly signed by the investigator, must be provided to you for future reference. Your childs participation in this research study is absolutely voluntary. You or your child can withdraw from this study at any time. In the event new information becomes available that may affect the risks or benefits associated with this research or your willingness to participate in it, you will be notified so that you can make an informed decision whether or not to continue your participation in this study. For additional information about giving consent or your rights as a participant in this study, please feel free to contact the MTSU Office of Compliance (Tel 615-494-8918 or send your emails to  HYPERLINK "mailto:irb_information@mtsu.edu" irb_information@mtsu.edu. Please visit  HYPERLINK "http://www.mtsu.edu/irb" www.mtsu.edu/irb for general information and visit  HYPERLINK "http://www.mtsu.edu/irb/FAQ/WorkinWithMinors.php" http://www.mtsu.edu/irb/FAQ/WorkinWithMinors.php for information on MTSUs policies on research with children Please read this section and sign Section C if you wish to enroll your child. The researcher will not enroll your child without your physical signature. Purpose of the study: Your child is being asked to participate in a research study because  FORMTEXT       General description of procedures to be followed and approximate duration of the study: The MTSU s classification of this study is  FORMCHECKBOX  Educational Tests Study involves either standard or novel education practices which consists educational testing and such studies expose the minors to lower than minimal risk  FORMCHECKBOX  Psychological and/or Behavioral Evaluation Although the study may or may not involve educational tests, the specific aim is to probe the childs behavioral ability.  FORMCHECKBOX  Physical Evaluation The children will be asked to perform or part-take in physical activities or procedures. Examples of such studies simple physical exercises, medical or clinical intervention, pharmaceutical testing and etc. Due to the nature of these studies, your child may be exposed to more than minimal risk.  FORMTEXT Provide Additional Information Here - DO NOT LEAVE BLANK What are we planning to do to your child in this study?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK What will your child be asked to do in this study?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK What are we planning to do with the data collected using your child?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK What are your expected costs, effort and time commitment:  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK What are the potential discomforts, inconveniences, and/or possible risks that can be reasonably expected as a result of participation in this study: For the Child:  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK For you the Parent:  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK How will you or your child be compensated for enrolling in this study?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK What are the anticipated benefits from this study?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Are there any alternatives to this study such that you or/and your child could receive the same benefits?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Will you or/and your child be compensated for study-related injuries?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Circumstances under which the Principal Investigator may withdraw your child from study participation:  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK What happens if you choose to withdraw from study participation?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Can you or/and your child stop the participation any time after initially agreeing to give consent/assent?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Contact Information. If you should have any questions about this research study or possibly injury, please feel free to contact  FORMTEXT PI Name by telephone  FORMTEXT PI Telephone or by email  FORMTEXT PI's email ID OR my faculty advisor,  FORMTEXT Faclty's Name - ENTER N/A if PI is not a student), at  FORMTEXT Enter a valid email ID and a telephone number. Confidentiality. All efforts, within reason, will be made to keep the personal information in your childs research record private but total privacy cannot be promised. Your information may be shared with MTSU or the government, such as the 鶹Ƶ Institutional Review Board, Federal Government Office for Human Research Protections, if you or someone else is in danger or if we are required to do so by law. Consent obtained by: Date Researcher s Signature Print Name and Title of the Researcher CHILD ASSENT (To be retained by the participating child who is over 12 years of age) Primary Investigator(s) FORMTEXT       Student  FORMCHECKBOX Contact information  FORMTEXT MTSU Office (If applicable), Telephone and Email IDDepartment Institution FORMTEXT      Faculty Advisor FORMTEXT      Department FORMTEXT      Study Title FORMTEXT      IRB IDNOT APPROVEDExpirationNOT APPROVED Child s Name (Age 12+) (type or print)  FORMTEXT        The following information is provided to you because your parents/guardians have agreed to enroll in the above identified research study. Please read this sheet carefully and feel free to ask any questions before you agree to enroll. The researcher must answer all of your questions before he/she asks you to do anything. Before you start: Make sure this sheet is signed by the researcher. Your participation is absolutely voluntary; you can decline anytime and your parents/guardians will not be notified. You are entitled to decline or withdraw at any time. Any new information on this research will be notified to you and you can decide whether to continue your participation based on the new information. Please visit  HYPERLINK "http://www.mtsu.edu/irb/FAQ/WorkinWithMinors.php" http://www.mtsu.edu/irb/FAQ/WorkinWithMinors.php or email  HYPERLINK "mailto:irb_information@mtsu.edu" irb_information@mtsu.edu or call 615 494 8918 more information. Why are you doing this research?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK What will the researcher do and how long will it take?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Do I have to be in this research study and can I stop if I want to?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Will anyone know that I am in this research study? No one will know you are participating in this study. However, information we collect on you may be shared with others ONLY if you or someone else is in danger or if we have to do so by law. How will this research help me or/and other people?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Can I do something else instead of this research?  FORMTEXT Provide Detailed Information here - DO NOT LEAVE BLANK Who do I talk to if I have questions?  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I understand I can withdraw my child from this study at any time without facing any consequences. ________________________ Date Signature of the Parent CHILD SECTION  FORMCHECKBOX No  FORMCHECKBOX Yes I have read this child assent document and I received a signed copy  FORMCHECKBOX No  FORMCHECKBOX Yes The researcher explained what they planned to do and all my questions were answered  FORMCHECKBOX No  FORMCHECKBOX Yes I understand what I was told  FORMCHECKBOX No  FORMCHECKBOX Yes I know the risks and I also know I can withdraw at any time ________________________ Date Signature of the Child Parental Consent obtained by: ________ Date Signature Print Name & Title Child Assent Administered by: ________ Date Signature Print Name & Title Faculty Verification if the PI is a student: ________ Date Faculty Signature DO NOT begin this Research before IRB approval      Institutional Review Board Office of Compliance 鶹Ƶ IRBF010d Combined Parental Consent Child Assent for 12+ years age Page  PAGE 5 of  NUMPAGES 5 IRB INSTITUTIONAL REVIEW BOARD Office of Research Compliance, 010A Sam Ingram Building, 2269 Middle Tennessee Blvd Murfreesboro, TN 37129 IRBF010d Version 1.0 Revision Date 05.26.2016 %&ֶŏseֶOֶ9+jy4hlohloCJOJQJUaJ+j4hlohloCJOJQJUaJhloCJOJQJ^JaJhm}CJOJQJ^JaJhAh CJOJQJ^JaJ hlohloCJOJQJ^JaJ+j3hlohloCJOJQJUaJhlohloCJOJQJaJ hlohloCJOJQJ^JaJ%jhlohloCJOJQJUaJ+j3hlohloCJOJQJUaJ&'*,IJVv>JKLMNOnʼʮʠʠʒʒʁjXGXG hGhloCJOJQJ^JaJ#hGhlo>*CJOJQJ^JaJ,hGhloB*CJOJQJ\^JaJph hlohGCJOJQJ^JaJhYoCJOJQJ^JaJhGCJOJQJ^JaJhloCJOJQJ^JaJhk&BCJOJQJ^JaJ hlohloCJOJQJ^JaJ hlohloCJOJQJ^JaJ%jhlohloCJOJQJUaJLMo"PQRt$a$gdAh $ a$gd!CN `^``gdYo `^``gd!CN$a$gd!CN$a$gd!CN $^a$gd!CN $ a$gdlo$a$gdlo´m^Hm7m^ hloh!CNCJOJQJ^JaJ+j4hloh!CNCJOJQJUaJhloh!CNCJOJQJaJ%jhloh!CNCJOJQJUaJ hloh!CNCJOJQJ^JaJ#h$h!CN5CJOJQJ^JaJ h!CN5>*CJOJQJ^JaJh!CNCJOJQJ^JaJhloCJOJQJ^JaJ h$hloCJOJQJ^JaJ hGhloCJOJQJ^JaJhYoCJOJQJ^JaJ!"#12389GHILNYŴ։s։]O։hYoCJOJQJ^JaJ+jQ6hloh!CNCJOJQJUaJ+j5hloh!CNCJOJQJUaJhloh!CNCJOJQJaJhk&BCJOJQJ^JaJhAh CJOJQJ^JaJ hloh!CNCJOJQJ^JaJ hloh!CNCJOJQJ^JaJ%jhloh!CNCJOJQJUaJ+je5hloh!CNCJOJQJUaJ8ֶŏpֶZֶDŏ+j)8hloh!CNCJOJQJUaJ+j7hloh!CNCJOJQJUaJ hYoh!CNCJOJQJ^JaJhk&BCJOJQJ^JaJ hloh!CNCJOJQJ^JaJ+j=7hloh!CNCJOJQJUaJhloh!CNCJOJQJaJ hloh!CNCJOJQJ^JaJ%jhloh!CNCJOJQJUaJ+j6hloh!CNCJOJQJUaJ8OPQRSTsӼ}l[J8J#hhAh >*CJOJQJ^JaJ hhloCJOJQJ^JaJ hhAh CJOJQJ^JaJ h$h!CNCJOJQJ^JaJhYoCJOJQJ^JaJh!CNCJOJQJ^JaJ hGh!CNCJOJQJ^JaJ#hGh!CN>*CJOJQJ^JaJ,hGhAh B*CJOJQJ\^JaJphh!CNCJOJQJ^JaJ hloh!CNCJOJQJ^JaJhAh CJOJQJ^JaJ#$7^_ $ *$a$gd hgdAh  hgdlo$a$gdAh $&'6sʹʹ۹۹۹۹wwiVNjheMU$hhAh 5B*CJOJQJphhAh CJOJQJ^JaJ$hth5B*CJOJQJphh5B*CJOJQJph hhCJOJQJ^JaJhCJOJQJ^JaJ hhAh CJOJQJ^JaJ hhloCJOJQJ^JaJ#hhAh >*䴳ϴ#l>*䴳ϴɸٴܸٴܲ<"h0lCJ2jhKph0l5CJOJQJU\^JaJ*.h e15CJOJQJ\^JaJmHnHu*&hKph0l5CJOJQJ\^JaJ/jhKph0l5CJOJQJU\^JaJ hKph0lCJOJQJ^JaJ h0lCJhKph0lCJaJh0lCJaJh0ljh0lUmHnHujheMUheMNOPQ.EFtuvw $ *$a$gdgd1xgd<"gdKpFstuvwѾ$hhAh 5B*CJOJQJphheMh<"h0lCJ h0lCJh0lh h0l5 h0l5CJh h0l5CJh h0l5CJ( h0l5CJ( 5 01h:pS'/ =!8"8##$#% nu.iw:.gEMK!PNG  IHDRktEXtSoftwareAdobe ImageReadyqe<.IDATx UUϬ ;JF`bQniejJm{٢VXIeef-d傆 j :0{y.3>ɲܳ۳f/Ŧ#G>ٲ<(G0u8 eVm}זk"$a}∩4LYhhh(Kz(qM@EīvLE*)N 3 㐣 !$(HURG @3$R"gC))@dt$R-  @6R]F ]A Cvh B ]A  vB  N50LW-`O)`סu?nպuȑ#_o>±ճܕ;ɮ}$A_+}voV^]@$R3!%1KEiw͍ ӟ `70tsHƫ@Brh\ѻwo#YGo?{w߇zHU}- :Ԙ";3zi`Ȑ!jRcǎ5|`hW%\HHO=m_Ml@tz5D^^hʔ)v¡0|3Q>9fc~Fj}&Hfkpc=6[#MEkw}ML̙3G};7xs9o޼Hx4gΜn ~N} G_sW*LWN%7cL<9l;STU~aذaj=PJpx/d7n\8h uaղe!e#q3fP_ |Wp:M?hÆ Fj/]TmܸplƭFqT7MjF}'u>Hgyy$ѣCO$+Hmڴ*?lu$ nXD]LQ3fLj_i6ᢲ'?QUUU!6}1Ql8 aH?P x-y߮?7`pV1"ȴ! 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