Human Subjects Institutional Review Board (HSIRB)

Consent of a responsible adult - sample

Western Michigan University
Department of: _________________
Principal Investigator: _________________
Student Investigator: _________________

You have been invited to participate in a research project entitled "(title)." This research is intended to study how mothers cope after the death of their infant child. This project is (student investigator's) dissertation project.

You will be asked to attend two one-hour private sessions with (the researcher). You will be asked to meet (the researcher) for these sessions at _________________. The first session will involve completing two questionnaires, the Beck Depression Inventory and the Symptom Checklist - 90.

You will also be asked to provide general information about yourself, such as age, level of education, and employment status. If the results of the questionnaires indicate significant signs of depression or anxiety, you will be excluded from the remainder of the study and will be provided with a therapist referral list. The second session will involve an interview during which you will be asked questions regarding the death of your infant, such as the circumstances under which the death occurred, and how you coped and/or are coping with the loss.

As in all research, there may be unforeseen risks to the participant. If an accidental injury occurs, appropriate emergency measures will be taken; however, no compensation or treatment will be made available to me except as otherwise specified in this consent form. One potential risk of participation in this project is that you may be upset by the content of the interview; however, (the researcher) is prepared to provide crisis counseling should you become significantly upset and s/he is prepared to make a referral if you need further counseling about this topic. You will be responsible for the cost of therapy if you choose to pursue it.

One way in which you may benefit from this activity is having the chance to talk about your loss, which research indicates is beneficial for individuals who are grieving the loss of a loved one. Others who experience a loss may benefit from the knowledge that is gained from this research.

All of the information collected from you is confidential. That means that your name will not appear on any papers on which this information is recorded. The forms will all be coded, and (the researcher) will keep a separate master list with the names of participants and the corresponding code numbers. Once the data are collected and analyzed, the master list will be destroyed. All other forms will be retained for at least three years in a locked file in the principal investigator's office.

You may refuse to participate or quit at any time during the study without prejudice or penalty. If you have any questions or concerns about this study, you may contact either (the researcher) at (phone number) or (the other researcher) at (phone number). You may also contact the chair of Human Subjects Institutional Review Board at 269-387-8293 or the vice president for research at 269-387-8298 with any concerns that you have.

This consent document has been approved for use for one year by the Human Subjects Institutional Review Board as indicated by the stamped date and signature of the board chair in the upper right corner. Do not participate in this study if the stamped date is more than one year old.

Your signature below indicates that you have read and/or had explained to you the purpose and requirements of the study and that you agree to participate.

__________________________________ _____________
Signature Date
Consent obtained by: _______________ _____________
  initials of researcher Date

Questions? E-mail the research compliance coordinator.

Office of the Vice President for Research
Western Michigan University
210 W Walwood Hall
Kalamazoo, MI 49008-5456 USA
(269) 387-8298 | (269) 387-8276 Fax