Cost of study medication, etc. MRI of the knee Blood tests for X, Y and Z Etc. (Include only if applicable) The following research procedures will be billed to you or your insurance: Any additional costs to subject as a result of study participation. Will you be paid for taking part in this Include one of the following statements You will not receive any payments for taking part in this study. or If there will be payments and/or reimbursement, the consent form should specify how much will be paid for reimbursement of expenses (not taxable) and the form (cash, check, gift card) and the timing of payment. Also specify how much is going to the parent and how much is going to the subject. See the IRB website and IRB SOP 704 for instructions regarding listing payments to subjects and parents and for prorating payments. Parents/participants will be reimbursed for travel, meals and parking. Receipts must be provided for all expenses. OR (for flat rate payments use the following) Parents/participants will be paid $XXXX to offset the costs of travel, meals and parking. Parents will be paid $XXXX for their time and effort. Children/participants will be paid $XXXX for their time and effort. If you receive payment using a bankcard, the bank will have access to identifiable information. The bank will not have access to any medical information. NOTE: If payment to an individual could exceed $600 (not including reimbursement for parking, meals, etc. based on receipts) in a calendar year, subjects will receive a W9 form. This should be explained verbally but need not go in the consent form. Who is funding this research study? Use one of the 3 statements below depending on which is most applicable. If there is no external funding source: The Division of XXXX at The Children’s Hospital of Philadelphia is funding this research. or The National Institutes of Health is providing funding for this study. or For industry sponsored studies: This study is supported by the SPONSOR. SPONSOR is a drug company that makes the medication being studied in this research project. SPONSOR is giving money to Children's Hospital for some of the costs of the study. The results of the study will be reported to SPONSOR. If the study shows that the STUDY
Cost of study medication, etc. MRI of the knee Blood tests for X, Y and Z Etc. (Include only if applicable) The following research procedures will be billed to you or your insurance: Any additional costs to subject as a result of study participation. Will you be paid for taking part in this Include one of the following statements You will not receive any payments for taking part in this study. or If there will be payments and/or reimbursement, the consent form should specify how much will be paid for reimbursement of expenses (not taxable) and the form (cash, check, gift card) and the timing of payment. Also specify how much is going to the parent and how much is going to the subject. See the IRB website and IRB SOP 704 for instructions regarding listing payments to subjects and parents and for prorating payments. Parents/participants will be reimbursed for travel, meals and parking. Receipts must be provided for all expenses. OR (for flat rate payments use the following) Parents/participants will be paid $XXXX to offset the costs of travel, meals and parking. Parents will be paid $XXXX for their time and effort. Children/participants will be paid $XXXX for their time and effort. If you receive payment using a bankcard, the bank will have access to identifiable information. The bank will not have access to any medical information. NOTE: If payment to an individual could exceed $600 (not including reimbursement for parking, meals, etc. based on receipts) in a calendar year, subjects will receive a W9 form. This should be explained verbally but need not go in the consent form. Who is funding this research study? Use one of the 3 statements below depending on which is most applicable. If there is no external funding source: The Division of XXXX at The Children’s Hospital of Philadelphia is funding this research. or The National Institutes of Health is providing funding for this study. or For industry sponsored studies: This study is supported by the SPONSOR. SPONSOR is a drug company that makes the medication being studied in this research project. SPONSOR is giving money to Children's Hospital for some of the costs of the study. The results of the study will be reported to SPONSOR. If the study shows that the STUDY
consent_without_hipaa_01-13-15.docx