ࡱ> GJFe bjbj 4$xj\xj\w(j j 8.J?^^^^^MMM>>>>>>>$@yC>MMMMM>^^>MF^^>M>64;=^ AFг^<>>0?0<`;D;D8=;D=MMM>>MMM?MMMM;DMMMMMMMMMj > : Consent to Participate in a Research Study Title of Study INTERVIEW Principal Investigator: Researcher X, Ph.D., Department of ----------, Co-investigator: Researcher Y, Ph.D., Department of ------------, You are invited to be a part of a research study that ------------. The purpose of the study is to ---------------. We are asking you to participate because -------------. This study is being funded by ----------------------. If you agree to be part of the research study, you will be asked to participate in one face-to-face interview at the location of your choice. The interview should take about one hour. We would like to audiotape the interview to make sure that our conversation is recorded accurately. You may still participate in the research even if you decide not to be taped. The discussion topics include -----------------------. We will also talk about ---------------. Participating in this research is completely voluntary. Even if you decide to participate now, you may change your mind and stop at any time. While you may not receive a direct benefit from participating in this research, some people find sharing their stories to be a valuable experience. We hope that this study will contribute to understanding -----------------------------. Answering questions or talking with others about ----------------- can be difficult. You may choose not to answer any interview question and you can stop your participation in the research at any time. The interviewer will have a list of support agency referrals, if you are interested in more information about community resources. You will be paid $--- if you complete the interview. If you decide stop before the interview is completed you will still receive $--- (optional). We plan to publish the results of this study but will not include any information that would identify you or your family members. To keep your information safe, the audiotape of your 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 and uses special coding of the data to protect the information. To protect confidentiality, your real name and your family members name will not be used in the written copy of the discussion. The researchers plan to keep this study data indefinitely for future research about _________. There are some reasons why people other than the researchers may need to see information you provided as part of the study. This includes organizations responsible for making sure the research is done safely and properly, including , government research offices, or the study sponsor---------------. Because this study -------------, if you tell us something that makes us believe that you or others have been or may be physically harmed, we may report that information to the appropriate agencies. If you have questions about this research, including questions about the scheduling of the interview or your payment for participating, you can contact Researcher X, , Department of ----------, address, Chicago, IL, (773) phone number, researcherx@csu.edu. You can also contact his/her faculty advisor, ----------------, Ph.D., , Department of --------, address, Chicago, IL, 60628 (773) phone number, faculty advisor@csu.edu. If you have any questions about your rights as aresearch participant, please contact the Institutional Review Board, (773) 995-2405, 9501 S. King Dr., Cook Administration Building Rm 304A, irb@csu.edu. By signing this document, you are agreeing to be part of the study. 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 questions you have about the study have been answered and that you understand what you are being asked to do. You may contact the researcher if you think of a question later. 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