ࡱ> ,.+ bjbjo>o> 0 T TPPPPPdddd pd,___$.bP=__==PP111= PP1=1114JG1m01BRB1BP1<_L61, 0______====B_________ : Appendix L MODEL FORM TITLE OF RESEARCH STUDY INFORMED CONSENT FORM (FOR MINORS) (Typically used for studies exceeding minimal risk) The elements of the Informed Consent Form for Adults are used with the following variations: 1. Investigator's name, who is title/position, at 58 has requested your child's participation in a research study. 2. [same as adult] 3. Your child's participation will involve... [Be sure to include the following no penalty statement: Your childs participation in this study is voluntary. If you choose not to have your child participate or to withdraw your child from the study at any time, there will be no penalty. It will not affect your childs (grade/treatment/care, etc., please choose the one that applies to the proposal). Likewise, if your child chooses not to participate or to withdraw from the study at any time, there will be no penalty.] 4. The possible risks or discomforts from your childs participation in the research are.. 5. The possible benefits of your child's participation in the research are... OR There is no direct benefit to your child anticipated from participating in this study. However, it is hoped that the information gained from the study will help... 6. The results of the research study may be published but your child's name or identity will not be revealed. In order to maintain confidentiality of your child's records, name of investigator will... 7. Payment for your child's participation is as follows: [same as adult] OR You will not be paid for your child's participation. 8. [same as adult] 9. [same as adult] 10. [same as adult] (Release statement for videotaping or relinquishing confidentiality must be inserted here if applicable.) _______________________________ _________________________ ____________ Signature Printed Name Date (Father, Mother, or Legal Guardian) 11. [same as adult] 12. [same as adult]    q H O Q LhY h5CJhG5>*CJ hGCJ hG5CJ hGCJ  0STr s L P $ 0\^`\a$gdG$ 0a$gdG$ 0a$gdG $ Ha$gdGP LM`s:^$ 0a$gdG$ 0\^`\a$gdG.:pG/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H GNormal CJOJPJQJ_HmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List p$@p M<Envelope Address!@ &+D/^@ CJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] P  8@0(  B S  ?"GI#GI$GI%GI&GIA%E$//?*urn:schemas-microsoft-com:office:smarttags stockticker=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsplace  x|J\4JQUdhx|3333333333swMQQ YX{<2GM<+e@@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial3TimesA$BCambria Math"h&&|U'% % !9243HP ?X{2!xx  Appendix LLinda CampbellTempOh+'0|  8 D P\dlt Appendix LLinda Campbell Normal.dotmTemp3Microsoft Office Word@Ik@k@@I%՜.+,0 hp  58   Appendix L Title  !"$%&'()*-Root Entry FPJ/1Table BWordDocument0SummaryInformation(DocumentSummaryInformation8#CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q