The University of Texas Southwestern Medical Center

Parkland Health & Hospital System

Children’s Medical Center

Retina Foundation of the Southwest

Texas Scottish Rite Hospital for Children

Texas Health Presbyterian Hospital Dallas

Consent to Participate in Research

You are being asked to participate in a research study.

Before you agree, the investigator must tell you about (i) the purposes, procedures, and duration of the research; (ii) any procedures which are experimental; (iii) any reasonably foreseeable risks, discomforts, and benefits of the research; (iv) any potentially beneficial alternative procedures or treatments; and (v) how confidentiality will be maintained.

Where applicable, the investigator must also tell you about (i) any available compensation or medical treatment if injury occurs; (ii) the possibility of unforeseeable risks; (iii) circumstances when the investigator may halt your participation; (iv) any added costs to you; (v) what happens if you decide to stop participating; (vi) when you will be told about new findings which may affect your willingness to participate; and (vii) how many people will be in the study.

If you agree to participate, you must be given a signed copy of this document and a written summary of the research.

You may contact _________________ at _________________ any time you have questions about the research.

You may contact the Institutional Review Board at (214) 648-3060 if you have questions about your rights as a research subject or what to do if you are injured.

Your participation in this research is voluntary, and you will not be penalized or lose benefits if you refuse to participate or decide to stop.

Signing this document means that the research study, including the above information, has been described to you orally, and that you voluntarily agree to participate.

____________________________________________
Name of Participant (Printed)
____________________________________________	________	_______ AM / PM
Signature of Participant	Date	Time

____________________________________________
Legally Authorized Representative’s Name (Printed)
____________________________________________	________	_______ AM / PM
Legally Authorized Representative’s Signature	Date	Time

____________________________________________
Name of Person Obtaining Consent (Printed)
____________________________________________	________	_______ AM / PM
Signature of Person Obtaining Consent	Date	Time

[If applicable:]

ASSENT OF A MINOR:

I have discussed this research study with my parent or legal guardian and the researchers, and I agree to participate.

____________________________________________	________	_______ AM / PM
Participant’s Signature (age 10 through 17)	Date	Time

[Insert if non-English short form is used:]

Interpreter/Witness Statement:

I have interpreted this consent form into a language understandable to the participant and the participant has agreed to participate as indicated by their signature above.

____________________________________________
Name of Interpreter (Printed)
____________________________________________	________	_______ AM / PM
Signature of Interpreter	Date	Time

Witness [Needed when the interpreter is not physically present, i.e. a language line is used]:

I attest that the information in the consent form was accurately explained to, and apparently understood by the subject or the subject's legal authorized representative, and that informed consent was freely given by the subject or the subject’s legal authorized representative.

____________________________	________ _______AM / PM

Name of Witness (Printed)	Date	Time

__________________________ ________ _______AM / PM

Signature of Witness Date Time