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Sample Informed Consent Form (for Minors)

[for studies exceeding minimal risk]

The elements of the Informed Consent for Adults may be used with the following variations:

Title of Research

I HAVE BEEN INFORMED THAT:

1. Researcher's name, who is [title/position at Southern Methodist University] has requested my minor child's (ward's) participation in a research study at this institution.

2. [same as adult]

3. My child's (ward's) participation will involve . . .

4. [same as adult]

5. [same as adult]

6. The possible benefits of my child's (ward's) participation in this reseach study are . . .

Or

Although there may be no direct benefits to my child (ward), the possible benefits of my child's (ward's) participation in this research study are . . .

7. The results of the research study may be published but my child's (ward's) name or identity will not be revealed. In order to maintain confidentiality of my child's (ward's) records, (researcher's name) will . . .

8. [same as adult]

9. [same as adult]

Or

I will not be paid for my child's (ward's) participation.

10. [same as adult]

11. [same as adult]

12. [same as adult]

[Release statement for audiotaping/videotaping or relinquishing confidentiality must be inserted here, if applicable].

Signature: _________________________________

Date: _______________________

Child's Name: _________________________________