Human Subjects Institutional Review Board (HSIRB)

Parent or guardian permission - sample

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

Your child has been invited to participate in a research project entitled "(title)." The purpose of the study is to determine the usefulness of two intelligence tests in preparing vocational evaluations and individualized transition plans. This project is being conducted to fulfill (the researcher's) thesis requirement.

Your permission for your child to participate in this project means that your child will be administered the Kaufman Brief Intelligence Test (K-BIT) and the Slosson Intelligence Test Revised (SIT-R). The testing will take place during April or May and will involve about one class period. Your child will be tested individually by someone trained in test administration who has also worked with special education students. Your child will be free at any time -- even during the test administration -- to choose not to participate. If your child refuses or quits, there will be no negative effect on his/her school programming. Although there may be no immediate benefits to your child for participating, there may eventually be benefits to the school district and subsequently to students in special education programs. If these tests are found to be useful, then current intellectual data could be obtained rather than relying on intellectual test scores that could be as many as two years old.

Your child's teacher will provide the researchers with scores from your child's latest intelligence test so they may be compared with these new scores. All test data and information will remain confidential. That means that your child's name will be omitted from all test forms and a code number will be attached. The principal investigator will keep a separate master list with the names of the children and the corresponding code numbers. If the researchers find that these two new tests are useful for planning your child's programming, they will share the results with your child's teacher. 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. No names will be used if the results are published or reported at a professional meeting.

The only risks anticipated are minor discomforts typically experienced by children when they are being tested (e.g., boredom, mild stress owing to the testing situation). All of the usual methods employed during standardized testing to minimize discomforts will be employed in this study. As in all research, there may be unforeseen risks to your child. If an accidental injury occurs, appropriate emergency measures will be taken; however, no compensation or treatment will be made available to me or your child except as otherwise specified in this permission form.

You may withdraw your child from this study at any time without any negative effect on services to your child. 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 the Human Subjects Institutional Review Board at 269-387-8293 or the vice president for research 269-387-9298 with any concerns that you have.

This permission 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 permit your child to participate if the stamped date is more than one year old.

Your signature below indicates that you, as parent or guardian, can and do give your permission for _______________________ (child's name)

  • to be tested with the Kaufman Brief Intelligence Test and the Slosson Intelligence Test-Revised;
  • for these scores, if found to be useful, to be reported to his/her teacher; and
  • for your child's latest individual intelligence test scores to be released to the researchers
  • ___________________________________ _____________
    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