UCAIHS | Consent Form Generator

Consent Form Generator

Purpose of the Study:

You have been invited to take part in a research study to learn more about

Example 1: the effect of time of day on reading comprehension.

Example 2: whether people make economic decisions differently when working in a group versus individually.

Example 3: how viewing pictures of natural disasters affects fear of terrorism.

Principal Investigator (PI) Information

If you are a student investigator, please enter your information here.

Preferred Gender Pronoun he/him/his she/her/hers they/them/their

Name

University Phone Number¹

University/Mailing Address¹

E-mail Address

NYU School (if applicable)

NYU Department (if applicable)

1 - Do not use home phone or address if at all avoidable.

Consent Form Generator

If the study is led by a student or post-doc please fill out this section. Otherwise, please click next to continue.

Faculty Sponsor Name

Faculty Sponsor Phone Number

Faculty Sponsor E-mail Address

University/Mailing Address

Faculty Sponsor School (if applicable)

Faculty Sponsor Department (if applicable)

Consent Form Generator

Type of Research:

Doctoral Dissertation Master's Thesis Class Project Faculty-directed Research
Other:

Description of Procedures:

If you agree to be in this study, you will be asked to do the following:

Example 1: Complete a questionnaire about your background (age, gender, education, etc.).

Example 2: Take part in an interview about your responses to two videos showing different hiring techniques for a job as a personnel director.

Example 3: Play three rounds of a computer game that asks you to be an auction buyer in competition with other buyers for a work of art.

If you need more than 5 items, add them manually in your word processing program once the draft has been generated.

Consent Form Generator

Length of Participation (total number & approximate length of sessions)

Participation in this study will take

Example: two hours of your time: 30 minutes to complete the questionnaire and approximately 45 minutes for each of the two interviews. The interviews will be held two weeks apart.

Session Recording (will the subject be recorded?)

None Audio Video Photo

Benefits & Risks

Are there more than minimal risks, i.e., beyond those of everyday life?

Yes No

If Yes, please describe:

Example 1: Although every effort will be made to prevent it, you may find the sensitive nature of some of the questions upsetting. In that event, the investigator will provide you with a referral to a counselor with whom you may discuss your feelings.

Example 2: There is a risk that you may have some muscle soreness for about four days.

Are there any direct benefits?

Yes No

If Yes, please describe (be sure to be reasonable in describing the likelihood and degree of the possible benefits):

Personal Injury (is there more than minimal risk and any possibility of personal injury?)

Yes No

Consent Form Generator

Compensation or Payments (are there travel reimbursements, gift certificates, etc?): Yes No

If Yes, please describe:

Methods to Protect Confidentiality:

Confidentiality of your research records will be strictly maintained by:

Example 1: assigning code numbers to each participant so that data is never directly linked to individual identity.

Example 2: keeping all completed forms in a locked cabinet only accessible to the investigator.

Example 3: submitting forms with no identifiers to a sealed drop box so that subjects are anonymous.

Will identifiable data be collected and de-identified data may be used for future research (Many funding agencies and journals require that data be placed in a repository or be available for future research)? Yes No

Will there be focus groups or group interviews? Yes No

Are there minors involved (< 18 years of age): Yes No

Will information be collected that may reveal suspicion of harm to oneself or others? Yes No

Does the study have an NIH Certificate of Confidentiality? Yes No

If Yes, list possible examples applicable to the research, e.g., information about suspicion of child abuse or neglect, suspicion of harm to yourself or others, reporting of communicable diseases. (ONLY include these examples if there is a law that mandates disclosure; many NYU researchers are not subject to mandated reporting laws in New York, even if the study includes children.etc. Check laws for local states and municipalities in which the research may occur):

Consent Form Generator

Data & Biospecimens

Will biospecimens be collected for whole genome sequencing? Yes No

If Yes, please describe possible types of biospecimens, e.g., blood, saliva, etc.:

Will biospecimens be used for commercial profit? Yes No

If yes, will the participant share in the commercial profit? Yes No

Will clinically relevant data be collected (e.g. diagnostic data, blood glucose levels, etc.)? Yes No

If yes: The following results of this study may be clinically relevant to you:

Will all subjects receive their results? Yes No

If no, will results be provided if they find a potential issue? Yes No

If applicable, explain the procedures and conditions under which clinically relevant individual results will be disclosed:

Consent Form Generator

IRB Study Number

Please enter your IRB # from Cayuse:

Is the study an NIH-funded clinical trial? Yes No

Quotes (will you quote subjects by name?):

Yes No

Nonparticipation or Withdrawal (only applicable if subjects are student or receive service from a related agency/organization):

Nonparticipation or withdrawal

Example 1: will not affect your services you receive at NYU.

Example 2: will not affect your grades or academic standing.

Consent Form Generator

Please check the form for accuracy before clicking the download button.

Clicking anywhere in the form will allow you to edit.

Clicking the 'Download Word Document' button will allow you to download the form as a Microsoft Word document.

Important reminders: Be sure to put your school letterhead on the form and make sure the signature area is not on a page by itself. Please check your form for spelling and grammar mistakes. Proofread for clarity!

Consent Form Generator

Designed to help NYU investigators prepare a draft Consent Form for use in an Application for Review to the NYU IRB.

The generator will fill in the Consent Form using NYU IRB standard language and format.

Where appropriate, examples of the types of information needed have been provided.

Language for Parental Permission and Child Assent are different and not provided by the consent form generator.

Do not use this generator for clinical trials.

Please remember to:

Write at no higher than a 10th grade level, using language appropriate for the population (e.g. those for whom English is a second language). Avoid technical language or discipline-specific terms.
Be consistent about using "you" to refer to the subject. For the investigator, use "the investigator" or "the researcher" to refer to the person carrying out the study. Do not refer to yourself, the investigator, as "I".