ࡱ> 685 bjbj.. 4DgDg kmmmmmm$JxSSS   Sk Sk   pJi: W0 :  L>, $)*.SSSSX R: Appendix H MODEL FORM LETTER OF CONSENT FOR ADULTS (Typically used for studies that would not exceed minimal risk or would qualify for exempted status except for the fact that there is audio-taping or video-taping of interviews, or because of the population involved (see HS Manual, IV.B.3. for discussion of such populations)) Dear _______________: I am a professor [a student under the direction of Professor _____________] in the Department/Division/College of ______________________________ 58. I am conducting a research study to (state purpose of study) . I am requesting your participation, which will involve ____________________. (Include the nature of the participation and the expected duration of the subject's participation). Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study at any time, there will be no penalty. It will not affect your grade, treatment/care, whichever applies. The results of the research study may be published, but your name will not be used. There is no direct benefit to you anticipated from participating in this study. However, it is hoped that the information gained from the study will help ______________________________________________. If you have any questions concerning the research study, please call me at ( ) ___-_____ or Dr. ___ at ( ) ___ - ____. Sincerely, (Researchers name) By signing below you are affirming that you are age 18 or over and are giving consent to participate in the above study. (Release statement for videotaping or relinquishing confidentiality must be inserted here if applicable.) ______________________ ____________________ ____________ Signature Printed Name Date If you have any questions about your rights as a subject/participant in this research, or if you feel you have been placed at risk, you can contact the Chair of the Human Subjects Committee, through Office of Research Compliance and Integrity at (408) 554-5591.   45 J K a b 0 1 I M N 2 3 w x .}~.hY hyCJ hCiCJh?h.\d hCi56 hCi6 hCi6>* hCi>* hCi5hCi0  45J K a b M N 2 3 rr `!0L]0^LgdCi ``!0L]0^LgdCi$ ``#L]^La$gdCi$ t"6$]^a$gdCi$ `#L]^La$gdCi$ #LL]L^La$gdCi $L^La$gdCi 3 w x }~ H!0L]0^LgdCi ``!0L]0^LgdCi21h:p2/ =!"#$% x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH H`H CiNormal CJOJPJQJ_HmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List p$p M<Envelope Address!@ &+D/^@ CJOJQJ^JaJNT@N Ci Block Text $ t"8]^8a$PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y " 3  8@0(  B S  ?h\ i\ j\ k\   9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType?*urn:schemas-microsoft-com:office:smarttags stockticker P -2IL3333`x3  YX{<EF.\dCi2M<y?ea`@ @UnknownG.[x Times New Roman5Symbol3. .[x Arial3.[x TimesC.,.{$ Calibri Light7..{$ CalibriA$BCambria Math"h{'{'55!903@P ?X{2!xx  Appendix HLinda CampbellSamantha Herman Oh+'0   @ L Xdlt| Appendix HLinda Campbell Normal.dotmSamantha Herman2Microsoft Office Word@F#@@5 ՜.+,0 hp  58  Appendix H Title  !"#$&'()*+,./012347Root Entry FpJ9Data  1TableWordDocument4SummaryInformation(%DocumentSummaryInformation8-CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q