ࡱ> ILHe bjbj 4.xj\xj\w) &&&&&:::8r,:/:mmm9999999;>9&mK"mmm9&&{9mF&&9m9v6Z8p v.7990/:F7Q?)jQ?0Z8Q?&Z8dmmm99dmmm/:mmmmQ?mmmmmmmmm > : [Date] [Address] Dear Parent: Researcher X, Ph.D. and Researcher Y, Ph.D. of ݮƵ, Department of ---------, invites your child to participate in a research study entitled ---------------. You and your child are being contacted because ---------------------------. We would like to talk with your child about ----------------------. The purpose of this study is to -------------------------------. We plan to ask ----- children between the ages of ---- and ----- to participate in our research. This study is being funded by -----------------. If you agree, your child will talk to an interviewer about topics such as -------------------. An interviewer will come to: (your home/the school/other location) to conduct the interview at a time convenient for you and your child. The interview is expected to take about ---- minutes to complete. We would like to audiotape the interview, but taping is not required for your child to be part of the study. Your childs participation in this study is completely voluntary. If you allow your child to be part of the study, you may change your mind and withdraw your approval at any time. Your child may choose not to be part of the study, even if you agree, and may refuse to answer an interview question or stop participating at any time. While your child may not directly benefit from participating in our interview, we hope that this study will contribute to the improvement of _____________________________. Answering questions about ------------------ may be difficult for your child. The interviewer has been trained to work with children and will stop the interview if your child seems upset. We have attached a list of support agency referrals to this letter if your child needs additional help coping with feelings. Your child will be paid $----- for completing the full interview. If your child decides not to finish the interview, your child will be paid $----. We plan to publish the results of this study, but will not include any information that would identify you, your child or family members. To keep this information safe, the audiotape of your childs interview will be placed in a locked file cabinet until a written word-for-word copy of the discussion has been created. As soon as this process is complete, the tapes will be destroyed. The researchers will enter study data on a computer that is password-protected. To protect confidentiality, your childs real name and the names of any family members will not be used in the written copy of the discussion. The study data will be destroyed at the end of the study. NOTE TO RESEARCHERS: IF THIS IS NOT TRUE, YOU SHOUD STATE WHAT WILL HAPPEN TO THE DATA. There are some reasons why people other than the researchers may need to see information your child provided as part of the study. This includes organizations responsible for making sure that the research is done safely and properly, including ݮƵ, government offices, or the study sponsor --------. Also, if your child tells us something in the interview that makes us believe that your child or others have been or may be physically harmed, we may report that information to the appropriate agencies. An interviewer will call you to make an appointment to interview your child. We hope that you will be willing to allow your child to share his/her experiences with us. If you have questions about this research study, you can contact Researcher X., ݮƵ, Department of ----, 9501 S. King Dr., Chicago, IL 60628, (773) phone number, or researcherx@csu.edu. If you have questions about your childs rights as a research participant, please contact the ݮƵ Institutional Review Board, 9501 S. King Dr, Cook Administration Building Rm. 304-A (773) 995-2405,  HYPERLINK "mailto:irb@csu.edu" irb@csu.edu. Sincerely, Researcher X, Ph.D. ݮƵ Department of ----------- address Chicago, IL 60628  Parental Permission By signing this document, you are agreeing to allow your child, _(childs name)______________, to be part of the study entitled -----------------. Your childs participation in this study is completely voluntary. If you allow your child to be part of the study, you may change your mind and withdraw your approval at any time. Your child may choose not to be part of the study, even if you agree, and may refuse to answer an interview question or stop participating at any time. You will be given a copy of this document for your records and one copy will be kept with the study records. Be sure that the questions you have asked about the study have been answered and that you understand what your child will be asked to do. You may contact the researcher if you think of a question later. 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JP0^P`056789;<>*B*CJH*OJQJS*TX\]^JaJo(ph......... r0 f7A`{4n#W +A]J G,0ZF                   tR\c                                            S1PPf{\[5b h  PPx 1~,%%*&+.c./778'=t(>DA`BlH~sH IhEO`S UVcV`Z`hfm"qyr+xZxO{j~mHt 3xdJe  j6=p xix6^wKxK) z%6y *X~mk9RAGJ~wy@h@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)Tahoma?= *Cx Courier New;WingdingsA$BCambria Math"h#r'z$r'ʪe'G j % j %20mm3H?y2!xx *CONSENT TO PARTICIPATE IN A RESEARCH STUDYRachel NosowskyCrystal Wiley-Brown0         Oh+'0  (4 T ` l x,CONSENT TO PARTICIPATE IN A RESEARCH STUDYRachel NosowskyNormalCrystal Wiley-Brown4Microsoft Office Word@j( @$&@d;9м@,u j՜.+,D՜.+,h$ hp  UMich Health System% m +CONSENT TO PARTICIPATE IN A RESEARCH STUDY Title 8@ _PID_HLINKSA`Aomailto:irb@csu.edu  !"#$%&'()*+,-./012345679:;<=>?ABCDEFGJKNRoot Entry Fp M@1Table?WordDocument 4.SummaryInformation(8DocumentSummaryInformation8@MsoDataStoreQp TNMKP24HECHIK==2Qp Item PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q