ࡱ> a bjbjrr L\L\2%XXXXXlll8l-@:"(###T)T)T)@?B?B?B?B?B?B?$BDf?XT)((|T)T)f?XX##?---T)FX#X#@?-T)@?--:<#)R;,??0-@$;]E)]E(<<h]EXx<T)T)-T)T)T)T)T)f?f?-T)T)T)-@T)T)T)T)]ET)T)T)T)T)T)T)T)T)> :  IRBF010a RESEARCH WITH MINORS PARENTAL PERMISSION (Parental Consent form for Minors UNDER 12 years) General Information Use this form for requesting parental consent for enrolling their child who is under 12 years old. Use the child assent form provided in the IRB forms page (IRBF010b/c). 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 sections: Parental Permission section signed by the researcher and given to the parent The signature section has to be signed by the parent: 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 if requested by the parent. This section will be retained by the researcher Barring the actual signatures, the text boxes in two 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 waivedIRBF0101dCombined parental consent child assent forms for minors 12+ yearsMandatory 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. 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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 Parental Consent obtained by: ________ Date PIs Signature PIs Name & Title Faculty Verification if the PI is a student: ________ Date Faculty Signature Print Name & Title DO NOT begin this Research before IRB approval      Institutional Review Board Office of Compliance 鶹Ƶ IRBF010a Parental Consent when the child is less than years age Page  PAGE 3 of  NUMPAGES 4 IRB INSTITUTIONAL REVIEW BOARD Office of Research Compliance, 010A Sam Ingram Building, 2269 Middle Tennessee Blvd Murfreesboro, TN 37129 IRBF010a Version 1.0 Revision Date 05.26.2016 345:;IJKNVmz~ȜɜֶŏseֶOֶ9+j(hlohloCJOJQJUaJ+j'hlohloCJOJQJUaJhloCJOJQJ^JaJhm}CJOJQJ^JaJhAh CJOJQJ^JaJ hlohloCJOJQJ^JaJ+j,'hlohloCJOJQJUaJhlohloCJOJQJaJ hlohloCJOJQJ^JaJ%jhlohloCJOJQJUaJ+j&hlohloCJOJQJUaJɜʜ͜Мܜ0NOĝНѝҝӝԝ՝֝ʼʮʮʠʠʏ{gP>#hGhlo>*CJOJQJ^JaJ,hGh P,B*CJOJQJ\^JaJph&h P,B*CJOJQJ\^JaJph&hloB*CJOJQJ\^JaJph hlohGCJOJQJ^JaJh P,CJOJQJ^JaJhGCJOJQJ^JaJhloCJOJQJ^JaJ hlohloCJOJQJ^JaJ hlohloCJOJQJ^JaJ%jhlohloCJOJQJUaJҝӝԝ՝)*+,-LM`Ԟ hgdAh  hgdlo$a$gdAh $a$gd!CN $^a$gd!CN $ a$gdlo$a$gdlo֝ם%')*+,-6MOPV^_hﾰraOa=O=a#hhlo>*CJOJQJ^JaJ#hhAh >*CJOJQJ^JaJ hhloCJOJQJ^JaJ hhAh CJOJQJ^JaJhAh CJOJQJ^JaJ h$h!CNCJOJQJ^JaJh!CNCJOJQJ^JaJhloCJOJQJ^JaJ h$hloCJOJQJ^JaJhlCJOJQJ^JaJ#hGhlo>*CJOJQJ^JaJ hGhloCJOJQJ^JaJhmwx}ÞĞӞ 01дТБp]p]pOhAh CJOJQJ^JaJ$hth5B*CJOJQJphh5B*CJOJQJph hhCJOJQJ^JaJ hh P,CJOJQJ^JaJ#hhAh >*CJOJQJ^JaJhCJOJQJ^JaJhCJOJQJ^JaJ hhAh CJOJQJ^JaJ hhloCJOJQJ^JaJh P,CJOJQJ^JaJ24578:;=>:ՠǠ1<"gdKp $ *$a$gd1235689;<>?AB̟֟۟ܟǼ϶s[A2jhKph0l5CJOJQJU\^JaJ*.hBb5CJOJQJ\^JaJmHnHu*&hKph0l5CJOJQJ\^JaJ/jhKph0l5CJOJQJU\^JaJ hKph0lCJOJQJ^JaJ h0lCJ hCJhKph0lCJaJh0lCJaJh0ljh0lUmHnHuhtljhtlU$hhAh 5B*CJOJQJph׫voe[TLF@<htl h0lCJ hCJh h0l5 h0l5CJh h0l5CJh h0l5CJ( h0l5CJ(jh0lUmHnHuh0lh<"h0lCJ2jhKph0l5CJOJQJU\^JaJ*.hBb5CJOJQJ\^JaJmHnHu*&hKph0l5CJOJQJ\^JaJ/jhKph0l5CJOJQJU\^JaJ hKph0lCJOJQJ^JaJ $ *$a$gd$hhAh 5B*CJOJQJph5 01h:pS'/ =!8"8##$#% 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! 8:@HY8*O?k@PI iDJHO⵰[Rz׻ԧ>")x7wJ.!AE5/>uW뮻=H.LM8HQ!׾D" :T}کVXK͟?ߨq?Hr fI8ONP_Wӟ@9GG2_~#(Wo(>7?Щ_.,|,ZH=߸=(ԟ8o .C& l"!+\x.!ayvx ;MvMwNIH '?IuG]ߊ}:Cqm8DɂxY ^,ΧB=c+꫙i*@]3% cV*,fΜi.T>:묳 .\hЬLg;0mܶm_N3n@HmH qXmo{zNJaqIBЇ>du|Yl{'NA|IxRDʢz8Zp`A88cjր&NCZ.w}?F"I'> C Ͻ tfOp>,uq`I8bK0 s0)I Z .H}7`͚5:(`Twqj„ 'KHTH,.$X'[=m-?~Wbjdž4S=@H- MHa O>.{t VQsas mBBm0HTIj.>+%4#!Eɶ] |jĈE,^Ⱦ6.R^ni,*& !㻢yդP̝8lċIǀD,DNj L>Qpy#lB)%WBx]dF|[ߺ g.$.@7!$!ו js0y{mBH8|e;#εJ %$$/6`ږާ"MfiW5@Hl^4o68@bU.*I1}MQ'IX;`ʕn(:9 /1w̃o.u BbwVpT`s1]W.p@]IJY),BHj$L߈8Y,huСN%5d`ԩl!.oW"ŵ jlx!$>%z7" <};ivkE f}Y5k֬{N:$/* <[$ ) B^yg w]C$M_B$g눚#qJΆNAHO>d[ j2M)Sbێې pID[Hbɤ_ .9cbB.燠'sa~;:R>ʮ <?Fd|WƋ$s( c"³#ݒ$2҅t꾴ڱ"fܢvq:-:0*ײԹ8.˴9ҲB|eҴ.:9ʊ6%C2){.9E8ێp(F//%޵^€嵗-<`L{>*axl7)z˅᜔ږ 7׋h6-]$"⼐Yu UMAq3ؔO^5%?2/pl0?/ۛM\?)ZAئxXS6}U3l"^ځYgǁ.Ҭŋ7;ջ?|S lBɌqn6K/p?69͍Cz75'.\بW^ye+œT>h(Zzu%]F!=X>qD&І{4jԨhРAf +W,xbR*/-"Es<1imP]3/jpO363gÇ79f>{sNteYC_\ij VWZ:-- u i{qv*Zl2<3x sQlCT ٚ)s-h=6 po g)i qwJ_4<}{ߋ}X$E%i'E黽iTX<=oMTi8LH&Zl"v+ުe צsHl&TDMcYoF"Om5eNPYqP$=c ׆'^$2FE])!d{Jl&JA쟤!:6ĥe3>%se~"#KomՎ2=-=EqeMZO4.3gQK_R4.XE#b9_t7i;܋'jcwC_4 ,488S&aqݹXhh0* cpcP;Νx≉v.-[Vqo抎:TU3ڡ֡zOKHDj7xl%q&DݎIoS]qGمJ9N lT"\Io "}%Tbj)DlZ|YY*$0fXiҗ[2WI5 "Y]E=T-T89W͓7oE1@H&Eʊ|@&!ؗ"BJ∪h"tXbvlcWG:VKSp'LbC} ڕlW!];#ia^{mv$@n/۫I= Z>p-ިc$So\G !,9 8mvmU HHF c`o|wOo,<i۵؟*aP̿?C<>3פ֝@rW5a}I|L]|ا^&;'l$8]8(b] fY} ur?}6$gol(g |9HRBG>b)̀!=@4mŕo(2[M9nFT8]$ I81nr,;v@fVW1LoF:G$A%8}1DᙃIaC ApP2+J^p'uxM`dĽ{uԮ T9duV&GdR$Z5".ok…fOBdJPBLj 76pxi~6@*%T bb62>ܰ<eϒTQgi;'ԿG߳L,S1gыL Uϕ" XV-ze3 Lxw-5jmUZV=Oj}zM(5U U6 ґAXԂBD%P#U}s1_ѷ1#=!ٵUꑗWn9DO>zFQGQ{a+[HcՖZrs@0oZ6G,XW; #HUYRW=wapcs>W uVlWT55cH&I=SaΣ7Alk a UrzkHPǪı=j H ul7zϫa|HyխGUhoey۪j*H_ vy&ҝς Ft}a@g4LZ=[to&0KmbԀ;vyÞ7jl&mfȞȏSy}~ ڕʍdMNM{q->u'Bf6M"![`HʁHs`нFTz[TP+y7lŜK)춝{)Nol47Ze~%lX7*Wrw+1.֜dM~!)@@HhB"K{$h^?z׎2%!!HNYHY7eIkEz,R-I8RG$:ɓ'ns_T@Jϔ-RSmBOQ՜{'bKaXiRqan4wqIHBDܒ$> q#*vD.*R ŋM:71{iC1sD-Ҁ1S񓛜b\{YC֑D2.,?bq_OҘ9' ;9\?(c'd,d}!xӧ2 (Heq)Өn!Ҝ,c*TSROVT $%zsTܢHswminl 1KF<i@sSMr>Fh̙sߤ6Bn65AyKxrgѨ%yJlFUH#9\I':h P9;kڜ4YZrrFhҥK m0^x)*]p~( %/iJ#՘2 -y&JT/J<8&k֥/[ wa,bph6IgZEp.2j"^ }H#Qdpj.?H*8)Sy.H\U:w[(HMTo,*IPLHONLZe ͟?_iPTbՒkd$r{-*)b CO<:s=k%msA8 ,) tl18s%1 ډ48#={vfA{Q{ d&}ݞI:6gi8(rCAGzc>oVӶ87>&@kzi M4B.#QMl$]$ncc&}h d"@\,l[ǭ4qH8 ; G 6"-K(š駟nT :eT8T!: 'NBrbPU*iV("Zo$b3&ꫯ6~\BI@W"zAfʤ@ "ia48dlBixGf1 bc>l'$q୤2-cNH2H="޴:l?ެ75[O% YI#:*qfx9.! 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