Hello this is a two part assignment. The discussion question part 1 and 2 needs to be completed by Saturday evening (1 page, answer highlighted questions and do assignment) and the informed consent and IRB application (just complete both the two forms) needs to be completed by Sunday evening. On the discussion question I will attach the step by step instructions on how to put the data into the program and how to download onto computer. For Assignment 2: Informed Consent Form and IRB Application, I will attach the two forms. The course book is :If needed Grove, S. K., Burns, N., & Gray, J. R. (2013). The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. St. Louis: Elsevier. Readings: Interpreting Research Outcomes Disseminating Research Findings Please click here to download Minitab®. For further help, consult the Frequently Asked Questions (FAQ). Discussion Question Using Minitab This week, you learned about the statistical software applications used to analyze data for research analysis. For this week's discussion, you will use Minitab to run descriptive statistics, create graphs and respond to the following: • How could you use Minitab descriptive statistics for data analysis research? • What are your plans for learning more about Minitab and how will the information you learned about this software be of benefit in your future analysis of research data? Refer to this week’s readings and video tutorials(Getting Started in Minitab Express for PC from youtube) before starting this two part discussion question assignment. You will also have access to the Assignment Resources Step-by-Step Guide, accessed through the Assignment Resources Icon located to the right of the grading criteria above. Step 1: Entering Data Open Minitab You will now use Minitab to enter a sample dataset by following the steps below and referring to the examples in the Assignment Step-by-Step guide. Begin by opening Minitab. Once open, you will see two windows. The Session Window is in the top half of the screen and the Worksheet is below. Only one window is active at a time. Dataset Options In many cases, researchers may have the data from their study in another software package like Microsoft Excel. However, if the data is not available in a software spreadsheet you can manually enter the data. You may now choose to populate your Minitab worksheet using the provided Excel worksheet in Option 1 or try Manual Data Entry by following the instructions in Option 2. Option 1: Using Excel to populate Minitab To access the Excel worksheet populated with data, go to the Data Set Icon located to the right of the grading criteria above. You can copy and paste the data set directly from Excel into Minitab. Or Option 2: Manual Data Entry In the Worksheet window, type “Age” in C1. Enter the numbers as shown in the dataset below. Enter the remaining data as shown below (set up your column labels i.e., variable). The measure reflects math anxiety and the study variables (cringe, uneasy, afraid, worried, understand) the math anxiety range is from 1–5 with low being the least and 5 the highest. Age Cringe Uneasy Afraid Worried Understand 28 5 3 4 4 3 34 2 5 3 2 1 25 4 4 4 2 5 56 3 4 3 1 2 23 5 4 3 3 4 29 1 5 3 2 3 30 3 3 5 2 5 59 2 5 5 1 2 45 4 2 5 3 3 38 1 2 4 1 1 33 3 2 4 3 2 47 4 2 3 4 5 24 1 5 3 4 4 29 5 4 2 1 3 53 3 1 5 2 1 48 4 4 1 5 3 27 2 5 4 3 4 34 4 4 3 2 5 26 4 5 2 3 2 36 5 5 5 4 3 Step 2: Run Descriptive Statistics Now that your data is in Minitab, you will look at the descriptive statistics for this dataset. Select the Ribbon at the top titled “Statistics,” and then select “Descriptive Statistics”. Under the “Data tab” select a variable, under the “Statistics tab” check all the boxes, then click “OK”. Discussion Question Part 1 How could you use Minitab descriptive statistics for data analysis research? Write about your experience running descriptive statistics. Use the results in the Session Window to support your response. Then add to your discussion with the information you learn when completing Step 3. Step 3: Minitab and Graphs You will now look at graphing. Select the Ribbon at the top titled “Graph,” then select “Histogram,” and then select “Simple.” Choose one of the variables and select "Ok". You can create other Histogram graphs by choosing different variables. You can also choose from the other ten graph choices shown on the Graph ribbon. Remember you can use the left navigation column to access your work. Discussion Question Part 2 What are your plans for learning more about Minitab and how will the information you learned about this software be of benefit in your future analysis of research data? Copy and paste your graph(s) in a Word document and attach to your discussion response. I could not find any examples of this however I am not sure if you can look at other tutors work from the site but there is an assignment example from professor markins(UC Berkeley) from studypool. Only things related to the project should be filled out. Assignment 2: Informed Consent Form and IRB Application By, submit the Informed Consent Letter and the South University IRB Application (please note that this is only an example and no data may be collected). • Informed Consent Letter o Procedure section is clear, described in detail, specific, and all inclusive. Written in lay language (as documented by reading level score). Includes risks and benefits relevant to study. Address assent (if applicable). Submit your assignment to the W9: Assignment 2 Dropbox by Monday, July 17, 2017. Assignment 2 Grading Criteria Maximum Points Completed IRB Application accurately for proposed study. 15 Informed Consent Letter addresses all required criteria. 15 Total: 30 Installing Minitab on PC Click the “Download MiniTab Express” button for the appropriate computer you are using – either PC or Mac. A task bar will display at the bottom of the screen. Click the small arrow next to the “Save” button and click the Save and Open option. The file will download as “minitab.zip” to your default download folder. Navigate to the setup file by double-clicking each folder in the dialog box where the Minitab Express zip file was downloaded. Once you have located the setup file, double click to launch the installation process. Click the “Yes” button to allow the program to make changes on the computer. Click the Next button and follow the instructions on the screen to complete the install of Minitab Express. Read the End-User License Agreement at your discretion, and then click the checkbox for “I accept the terms in the License Agreement”. Click “Next”: You will then see the following window. Click the “Install” button. The Minitab Express program dialog will prompt you when the installation is completed. Click the “Finish” button. You will now be able to launch Minitab Express from the start button on your computer. THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. INSTITUTIONAL REVIEW BOARD FOR THE PROTECTION OF HUMAN SUBJECTS IN RESEARCH This form is to be used for requesting IRB review for exempt, expedited and full board studies Please note that handwritten and/or incomplete forms will be returned to you. CHECKLIST FOR IRB APPLICATION SUBMISSION (to be completed by PI before submission to IRB) Application Form with Signatures/ Confidentiality Agreements NIH Training Certificate(s) Protocol or Attached Research Proposal and/ or Contract/ Grant Solicitation Announcements/Recruitment Flyers Data Collection Instruments/Research Questions/Questionnaires/Surveys Informed Consent Documents Parental/Legal Guardian Permission Form (if applicable) Child Assent Form (if applicable) Approval from Study Sites (if applicable) Medical Screening Instrument (if applicable) Debriefing Plan (if applicable) Student as Principal Investigator Worksheet (if applicable) Page 1 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. Project Title PART I - INVESTIGATOR and RESEARCH PERSONNEL 1) PRINCIPAL INVESTIGATOR (Undergraduate students cannot serve as Principal Investigator, but may be listed as a Co-Investigator.) Name: Dr. Mr. Ms. Professor Dr. Mr. Ms. Professor Highest Degree Completed: Investigator Status: Faculty Graduate Student Staff E-mail Address: College/Department: Campus Mailing Address: Daytime Phone: 2) CO-INVESTIGATOR – 1 (if applicable) Name: Highest Degree Completed: Investigator Status: Faculty Other Graduate Student Undergraduate Staff E-mail Address: College/Department: Campus Mailing Address: Daytime Phone: 3) CO-INVESTIGATOR – 2 (if applicable) Dr. Name: Mr. Ms. Professor Highest Degree Completed: Investigator Status: Faculty Other Graduate Student Undergraduate Staff E-mail Address: College/Department: Campus Mailing Address: Daytime Phone: 4) FACULTY SPONSOR (if applicable) Name: Highest Degree Completed: E-mail Address: College/Department: Campus Mailing Address: Daytime Phone: Page 2 of 15 Dr. Mr. Ms. Professor THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. 5) STUDENT INVESTIGATORS/RESEARCH ASSISTANTS (if applicable) Name: E-mail: Phone: Name: E-mail: Phone: Name: E-mail: Phone: Name: E-mail: Phone: Name: E-mail: Phone: PART II – FUNDING INFORMATION 1) Check all of the appropriate boxes for funding sources for this research. Include pending funding source(s). Extramural College Department Other: P.I. of Grant or Contract: Sponsor: Contract/Grant No. (if available): Contract/Grant Title: ***Please provide one complete copy of the proposal submitted to the sponsor with this application. Please note that submission of your grant application is a regulatory requirement and will be maintained for the record with your application. The IRB will not utilize the grant during the review process other than to confirm that the grant proposal is consistent with the IRB proposal. You must submit all necessary documentation for the application in addition to the copy of the grant. PART III – EDUCATION AND TRAINING All research personnel (faculty, staff, graduate students working on a thesis or dissertation, anyone using data for purposes of independent research, students involved in data collection, faculty sponsors, persons receiving grant monies for human subject research or those personnel with management responsibilities) must complete this section. 1) Have all key research personnel completed the required NIH training? No Yes ***If No, DO NOT submit this application. Your application will not be considered until you have completed the IRB training and can provide a copy of your NIH course completion certificate. (Please include a copy/copies of all certificate(s) with each application.) ***Please note that this NIH training is a mandatory requirement to be completed every three years. ***If you have not completed the NIH training, but have completed a comparable course (e.g. CITI training), please include documentation of those courses. 2) If other necessary training/education is required for completion of this study, please attach copies of certificates or other documentation (e.g., HIPAA training, phlebotomy training). Page 3 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. PART IV – INVESTIGATOR ASSURANCE 1) • • • • • • • • • • • Institutional Review Board Policy Compliance Agreement I certify that the information provided in this application is complete and correct. I understand that as Principal Investigator, I have the responsibility for the conduct of the study, the ethical performance of the project and the protection of the rights and welfare of human participants. I agree to comply and to assure that all affiliated personnel comply with all South University IRB policies and procedures, as well as with all applicable federal, state and local laws regarding the protection of human participants in research. I agree that I have the appropriate expertise to conduct this study. I assure that this study is performed by qualified personnel adhering to the South University IRB approved protocol. Student PI’s must attach student PI worksheet (see appendix A). I assure that no modification to the approved protocol and consent materials will be made without first submitting for review and approval by the South University IRB an amendment to the approved protocol. I agree to obtain legally effective informed consent from the research participants as applicable to this research and as prescribed in the approved protocol. I will promptly report unanticipated problems to the South University IRB by using the Notification Form provided on the IRB website. I will adhere to all requirements for continuing review and will complete a Continuance Request form if my research extends beyond one year. I will advise the South University IRB of any change of address or contact information as long as this protocol remains active. I assure that I have obtained all necessary approvals from entities other than South University IRB that are necessary to conduct this research (e.g., cooperation letters or approvals from other institutions). My signature below certifies that I am knowledgeable about the regulations and policies governing research with human subjects and have sufficient training and experience to conduct this particular study in accordance with the research protocol. Principal Investigator Date (mm/dd/yyyy) Co-Investigator Date (mm/dd/yyyy) Faculty Sponsor Date (mm/dd/yyyy) Page 4 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. 2) • • • • Confidentiality Agreement I have agreed to assist with the research project described in this application. I agree not to discuss or disclose any of the content or personal information contained within the data, tapes, transcriptions, or other research records with anyone other than the Principal Investigator, Co-Investigator, or in the context of the research team. I agree to maintain confidentiality at all times and to abide by the South University IRB Policy and Procedures Manual. If I am aware of any breach in confidentiality, I am required to report violations of confidentiality to the IRB Committee Director, who will report this information to the College Dean and the Vice Chancellor of Academic Affairs. Principal Investigator Date (mm/dd/yyyy) Co-Investigator Date (mm/dd/yyyy) Faculty Sponsor Date (mm/dd/yyyy) Student Investigator Date (mm/dd/yyyy) Student Investigator Date (mm/dd/yyyy) Student Investigator Date (mm/dd/yyyy) Page 5 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. PART V – ADMINISTRATIVE DATA 1) Proposed duration of data collection/analysis Start date: End date: ***South University IRB policy dictates that project approvals may be granted for a maximum of one year, although the exact approval term will be determined based on the level of participant risk inherent in the proposal. Should the PIs need an extension beyond the proposed duration, they can apply by completing the Continuance Request Form. 2) If this research will result in a thesis or dissertation, please check the appropriate box. Undergraduate Level Project (Thesis, Capstone) Masters Level Project (Thesis, Capstone) Doctoral Level Project (Dissertation, Capstone) 3) Conflict of Interest Is there any potential or perceived conflict of interest between the researcher, sponsor and/or South University associated with this study? No Yes ***If yes, please explain, including any and all possible conflicts: 4) Study population a. Maximum Number of Participants Proposed: b. Age Range: c. Gender: to Males (include low/high age range) Females d. Site of Subject Recruitment: ***Please note that if recruitment will be conducted at any physical site other than South University, you will need to include a letter from management of the proposed site indicating their approval of your use of the facility. e. Will medical clearance or medical screening be necessary for participants to participate because of tissue or blood sampling, administration of substances such as food or drugs, or physical exercise conditioning? No Yes ***If yes, explain how clearance will be obtained. If a screening instrument will be used, please attach a copy to the application. Page 6 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. 5) Potentially Vulnerable Populations. Please check any groups included in the study. Children (under 18 years of age) Pregnant Women Elderly (65 & older) Psychologically Impaired Cognitively Impaired Prisoners Native American Tribes and/or Tribal Organizations Students currently enrolled in a class instructed by the investigator *** If you checked any of the above groups, your proposal will require full board review. 6) Study Site: ***Please note that if research will be conducted at any physical site other than South University, you will need to include a letter from management of the proposed site indicating their approval of your use of the facility. PART VI – SUMMARY OF STUDY ACTIVITIES ***Submission of a copy of a grant application or project proposal does not replace completion of this form. If additional space is required, you may attach a separate document, but please respond to each item in this section and label your responses accordingly. Incomplete proposals will be returned to you. 1) Provide background information for the study including the objective of the proposed research, purpose, research question, hypothesis and other information deemed relevant. 2) Describe the research design of the study (i.e., state whether the study is correlational, experimental, etc. and define the variables). Page 7 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. 3) Describe the tasks that participants will be asked to perform including a step-by-step description of the procedures you plan to use with your subjects. Provide the approximate duration of subject participation for each procedure/ instrument and the frequency and setting of each administration. Identify any personnel who will assist with data collection. ***You must submit a copy of each study instrument, including all questionnaires, surveys, protocols for interviews, etc. ***If someone will be assisting with data collection, but is not indicated as a co-investigator or research assistant in this application (i.e. they will be accessing archival data for you) you must submit a letter of approval indicating that they are willing and capable to assist. 4) Describe the recruitment procedures. Explain who will approach potential participants and take part in the research study and what will be done to protect the individual’s privacy in this process. ***You must submit a copy of any material used to recruit subjects (e.g., informed consent forms, advertisement, flyers, telephone scripts, verbal recruitment scripts, cover letters, etc.) 5) Describe how participants will be debriefed. ***If deception is used, the principal investigator should offer the participant the opportunity to withdraw his/her data after being debriefed, and this information should be included in the debriefing script. Page 8 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. PART VII – PRIVACY PROCEDURES 1) Will data be recorded by audiotape? Will data be recorded by videotape? Will photographs be taken? No No No Yes Yes Yes a. How will subjects be identified in these recordings? b. Explain your plan for disposal of tapes/photographs/negatives, including when this disposal will occur (i.e. after transcription/development or at the conclusion of the study). ***If you wish to retain the tapes/photographs/negatives beyond transcription/development, you must provide justification. ***Subjects must be informed of the collection and disposal of the tapes/photographs/negatives via the informed consent process. 2) Will you record any direct identifiers (e.g.,, names, social security numbers, addresses, telephone numbers, etc)? No Yes a. Explain why it is necessary to record these identifiers. Page 9 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. b. Describe the coding system you will use to protect against disclosure of these identifiers. c. Describe how subject identifiers will be maintained or destroyed after the study is completed. ***If you will retain a link between the study code numbers and direct identifiers after the data collection is complete, explain why this is necessary and state how long you will keep this link. d. Will you provide a link or identifier to anyone outside the research team? No Yes ***If yes, explain why and to whom. 3) Where, how long, and in what format (such as paper, digital or electronic media, video, audio or photographic) will data be kept? In addition, describe what security provisions will be taken to protect these data (password protection, encryption, etc). Page 10 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. 4) Will you place a copy of the consent form or other research study information in the participant’s record such as medical, personal or educational record? No Yes ***If yes, explain why this is necessary. ***This information should be clearly explained in the consent document and/or process. 5) Will any record of the subject’s participation in this study be made available to his or her supervisor, teacher, or employer? No Yes ***If yes, please explain why this is necessary . 6) Will you obtain a Federal Certificate of Confidentiality for this research? No Yes ***If yes, submit documentation of application (and a copy of the Certificate of Confidentiality award if granted) with this application form. If the data collected contain information about illegal behavior, visit the NIH Certificates of Confidentiality Kiosk http://grants1.nih.gov/grants/policy/coc for information about obtaining a Federal Certificate of Confidentiality. PART VIII – INFORMED CONSENT INFORMATION 1) Informed Consent: Please attach, as an appendix, an informed consent document to this application. South University IRB requires that all activity involving human subjects be carried out only AFTER obtaining proper consent from the participants of the research. Thus an information sheet or cover letter that contains all required elements of informed consent must be attached to this application. You may access a template for this form on the South University IRB website. (Please attach an assent form for children/youth participation and permission forms for parents/legal guardians; or consent forms for adult participation). 2) Request for Waiver of Informed Consent: Are you requesting a waiver of informed consent? No Yes Page 11 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. ***If yes, provide a written justification for a waiver of informed consent according to Section 46.116 of 45 CFR 46 (http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html#46.116). 3) Request for Waiver of Documentation of Consent (applies to studies that do not wish to have signatures of the participants, i.e. internet research): Are you requesting a waiver of documentation of consent? No Yes ***If yes, provide a written justification for a waiver of documentation of consent according to Section 46.117 of 45 CFR 46 (http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html#46.117). PART IX – RISKS AND BENEFITS 1) Does the research involve any of the possible risks or harms to subjects listed below? No Yes ***If Yes, independent scientific review may be required to determine if scientific merit justifies this risk. Check all that apply: Use of deception ***If deception is used, describe in detail here, including the debriefing process and script. ***If deception is used, the principal investigator should offer the participant the opportunity to withdraw his/her data after being debriefed, and this information should be included in the debriefing script. Page 12 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. Use of confidential records (e.g. educational or medical records) Manipulation of psychological or social variables such as sensory deprivation, social isolation, psychological stressors Presentation of materials which subjects might consider sensitive, offensive, threatening or degrading Possible invasion of privacy of subject or family Social, legal, or economic risk Employment/occupational risk Students of the researcher Subordinates and colleagues of the researcher Residents of any facility (i.e., prison) Pregnant women Children and minors Elderly subjects (65+ years of age) Wards of the state Mentally and emotionally disability Individuals who are not fluent in English Other risks (specify): 2) Describe the nature and degree of the risk or harm checked above. ***The described risks/harms must be disclosed in the consent form. Page 13 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. 3) Explain what steps will be taken to minimize risks or harms and to protect subjects’ welfare. If the research include protected populations (See Part V, Item 5 above), please identify each group and answer this question for each group. 4) Describe the anticipated benefits of this research for individual participants in each subject group. If none, state “none”. 5) Describe the anticipated benefits of this research for society, and explain how the benefits outweigh the risks. PART X – COMPENSATION INFORMATION 1) Will any compensation or inducements, i.e. course credit, be offered to the subjects for their participation? No Yes If yes, describe those inducements and include a statement in the informed consent document explaining how compensation will be handled in the event the participant withdraws from the study. ***If yes, describe those inducements. ***The informed consent document must include a statement explaining how compensation will be handled in the event that the participant withdraws from the study. Page 14 of 15 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S IRB APPLICATION AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. APPENDIX A: Student as Principal Investigator Worksheet Level: Masters Doctorate This project has been reviewed to determine that the scope, anticipated risks and benefits, and methodology are appropriate for this research by: Approval of thesis/dissertation proposal by faculty committee My personal review and approval of research proposal Other: The student researcher is qualified to conduct independent research based on the following credentials (check all that apply): has completed a graduate research methods course has experience as an independent or closely supervised research assistant has completed NIH training Other: FACULTY SPONSOR’S ASSURANCE By my signature as sponsor on this research application, I certify that the student is knowledgeable about the regulations and policies governing research with human subjects and has sufficient training and experience to conduct this particular study in accordance with the research protocol. Additionally, • • • • • • I hereby confirm that I have thoroughly reviewed this IRB application, including the protocol narrative, and deem it ready for submission. I agree to meet with the investigator on a regular basis to monitor study progress. I agree to be available, personally, to assist the investigator in solving problems, should they arise during the course of the study. I assure that the investigator will promptly report unanticipated problems and will adhere to all requirements for continuing review. If I am unavailable, e.g. sabbatical leave, vacation, or resignation, I will arrange for an alternate faculty sponsor to assume responsibility during my absence, and I will advise the South University IRB, in writing, of such changes. The research is appropriate in design. Print Faculty Sponsor Name Faculty Sponsor Signature Date (mm/dd/yyyy) Print PI Name PI Signature Page 15 of 15 Date (mm/dd/yyyy) THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S INFORMED CONSENT LETTER AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. For Official Use Only Date received: Date reviewed: End date: File #: SELF CONSENT I have been invited to take part in a research study titled: This study is being conducted by , who can be contacted at: I understand that my participation is voluntary and that I can refuse to participate or stop taking part any time without giving any reason and without facing any penalty. Additionally, I have the right to request the return, removal, or destruction of any information relating to me or my participation. PURPOSE OF STUDY I understand that the purpose of the study is to: PROCEDURES I understand that if I volunteer to take part in this study, I will be asked to: BENEFITS I understand that the benefits I may gain from participation include: RISKS I understand that the risks, discomforts, or stresses I may face during participation include: Page 1 of 2 THIS IS AN EXAMPLE OF SOUTH UNIVERSITY’S INFORMED CONSENT LETTER AND IS ONLY TO BE COMPLETED AND SUBMITTED AS AN ASSIGNMENT FOR NSG6101. CONFIDENTIALITY I understand that the only people who will know that I am a research subject are members of the research team. No individually-identifiable information about me, or provided by me during the study will be shared with others except when necessary to protect the rights and welfare of myself and others (for example, if I am injured and need emergency care, if the provided information concerns suicide, homicide, or child abuse, or if revealing the information is required by law). FURTHER QUESTIONS I understand that any further questions that I have, now or during the course of the study can be directed to the researcher ( ). Additionally, I understand that questions or problems regarding my rights as a research participant can be addressed to Dr. Jessica Hillyer, Institutional Review Board Director of Compliance and Training, South University, 7700 W. Parmer Ln., Austin, TX 78729; jhillyer@southuniversity.edu; 512-516-8779. My signature below indicates that the researchers have satisfactorily answered all of my current questions about this study and that I understand the purpose, procedures, benefits, and risks described above. I have also been offered a copy of this form to keep for my own records. Participant Printed Name Signature of Participant Date (mm/dd/yyyy) Signature of Principal Investigator Date (mm/dd/yyyy) Page 2 of 2
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