Informed - Consent Template GAS

Informed Consent
TITLE OF STUDY
[Insert title]
PRINCIPAL INVESTIGATOR
[Name]: NICOLE ANN B. BARONIA
[Department]:
[Address]: PAGASA DRIVE, RAWIS LEGAPI CITY
[Phone]: 09564182518 number of the leader
[Email]: [email protected] gmail acc of the leader
PURPOSE OF STUDY
You are being asked to take part in a research study. Before you decide to participate in
this study, it is important that you understand why the research is being done and what it
will involve. Please read the following information carefully. Please ask the researcher if
there is anything that is not clear or if you need more information.
The purpose of this study is to [Briefly describe purpose of study.]
STUDY PROCEDURES
List all procedures, preferably in chronological order, which will be employed in the
study. Point out any procedures that are considered experimental. Clearly explain
technical and medical terminology using non-technical language. Explain all procedures
using language that is appropriate for the expected reading level of participants.
State the amount of time required of participants per session, if applicable, and for the
total duration of the study.
If audio taping, videotaping, or film procedures are going to be used, provide

information about the use of these products.
RISKS
List all reasonably foreseeable risks, if any, of each of the procedures to be used in the
study, and any measures that will be used to minimize the risks.
You may decline to answer any or all questions and you may terminate your involvement
at any time if you choose.
BENEFITS
List the benefits you anticipate will be achieved from this research. Include benefits to
participants, others, or the body of knowledge. If there is no direct benefit to the
participant, state so. For example, “There will be no direct benefit to you for your
participation in this study. However, we hope that the information obtained from this
study may….”
Page 1 of 3
Participant’s Initials: ________
Informed Consent
When applicable, disclose alternative procedures or courses of treatment, if any, which

might be advantageous to participants.
CONFIDENTIALITY
Your responses to this [survey] will be anonymous. Please do not write any identifying
information on your [survey]. OR For the purposes of this research study, your comments
will not be anonymous. Every effort will be made by the researcher to preserve your
confidentiality including the following:
[State measures taken to ensure confidentiality, such as those listed below:
 Assigning code names/numbers for participants that will be used on all research
notes and documents
 Keeping notes, interview transcriptions, and any other identifying participant
information in a locked file cabinet in the personal possession of the researcher.]
Participant data will be kept confidential except in cases where the researcher is legally
obligated to report specific incidents. These incidents include, but may not be limited to,
incidents of abuse and suicide risk.
COMPENSATION
If there is no compensation, delete this section.

Indicate what participants will receive for their participation in this study. Indicate other
ways participants can earn the same amount of credit or compensation. State whether
participants will be eligible for compensation if they withdraw from the study prior to its
completion. If compensation is pro-rated over the period of the participant's involvement,
indicate the points/stages at which compensation changes during the study.
CONTACT INFORMATION
If you have questions at any time about this study, or you experience adverse effects as
the result of participating in this study, you may contact the researcher whose contact
information is provided on the first page. If you have questions regarding your rights as a
research participant, or if problems arise which you do not feel you can discuss with the
Primary Investigator, please contact the Institutional Review Board at (865) 354-3000,
ext. 4822.
VOLUNTARY PARTICIPATION
Your participation in this study is voluntary. It is up to you to decide whether or not to

take part in this study. If you decide to take part in this study, you will be asked to sign a
consent form. After you sign the consent form, you are still free to withdraw at any time
and without giving a reason. Withdrawing from this study will not affect the relationship
you have, if any, with the researcher. If you withdraw from the study before data
collection is completed, your data will be returned to you or destroyed.
Page 2 of 3
Informed Consent
Note: Please delineate the "Consent" section of the Informed Consent Form by drawing a
line across the page (like the one above this paragraph). This delineation is important
because the consent form grammar shifts from second person to first person, as shown in
this example. [TATANGALIN DAW THIS]
CONSENT
I have read, and I understand the provided information and have had the opportunity to
ask questions. I understand that my participation is voluntary and that I am free to
withdraw at any time, without giving a reason and without cost. I understand that I will
be given a copy of this consent form. I voluntarily agree to take part in this study.
Name of Participant (Print): _________________________

Signature: __________________________ Date: ___________
Name of Parent/Guradian (Print): _________________________

Signature: __________________________ Date
Person Obtaining the Consent (Print): _________________________

Signature: __________________________ Date
Page 3 of 3

Informed - Consent Template GAS

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Informed Consent

If audio taping, videotaping, or film procedures are going to be used, provide

When applicable, disclose alternative procedures or courses of treatment, if any, which

If there is no compensation, delete this section.

Your participation in this study is voluntary. It is up to you to decide whether or not to

Name of Participant (Print): _________________________

Name of Parent/Guradian (Print): _________________________

Person Obtaining the Consent (Print): _________________________

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