My signature below documents that the information in the consent document and any other written information was accurately explained to, and apparently understood by, the subject, and that consent was freely given by the subject. Signature of witness to consent process Date Printed name of person witnessing consent process Signature Block for Children Your signature documents your permission for the named child to take part in this research. Printed name of Signature of parent or individual legally authorized to consent to Date the child’s general medical care ____ Parent ____ Individual legally Printed name of parent or individual legally authorized to authorized to consent to the consent to the child’s general medical care child’s general medical care (See note below) Note: Investigators are to ensure that individuals who are not parents can demonstrate their legal authority to consent to the child’s general medical care. Contact legal counsel if any questions arise. Signature of parent Date Printed name of parent If signature of second parent not obtained, indicate why: (select one) _____ The IRB determined that the permission of _____ Second parent is incompetent one parent is sufficient. [Delete if the IRB did not _____ Second parent is not reasonably make this determination] available _____ Second parent is deceased _____ Only one parent has legal responsibility _____ Second parent is unknown for the care and custody of the child
My signature below documents that the information in the consent document and any other written information was accurately explained to, and apparently understood by, the subject, and that consent was freely given by the subject. Signature of witness to consent process Date Printed name of person witnessing consent process Signature Block for Children Your signature documents your permission for the named child to take part in this research. Printed name of Signature of parent or individual legally authorized to consent to the child’s general medical care Date ____ Parent ____ Individual legally authorized to consent to the child’s general medical care (See note below) Printed name of parent or individual legally authorized to consent to the child’s general medical care Note: Investigators are to ensure that individuals who are not parents can demonstrate their legal authority to consent to the child’s general medical care. Contact legal counsel if any questions arise. Signature of parent Date Printed name of parent If signature of second parent not obtained, indicate why: (select one) _____ The IRB determined that the permission of one parent is sufficient. [Delete if the IRB did not make this determination] _____ Second parent is deceased _____ Second parent is unknown _____ Second parent is incompetent _____ Second parent is not reasonably available _____ Only one parent has legal responsibility for the care and custody of the child
Consent-Template.docx