Investigators: [LIST NAMES, POSITIONS, DEPARTMENTAL AFFILIATIONS, AND TELEPHONE NUMBERS OF INVESTIGATORS]
Researcher's statement
PURPOSE AND BENEFITS
We want to do a science study. Some children get many earaches. Some do not. Maybe there is something in the blood that keeps some children from getting earaches. We want to test your blood to see if you have this substance. Maybe we can learn how to stop earaches in the future.
PROCEDURES
If you agree, we will take a teaspoon of your blood. We will use a clean needle to take the blood from your arm. We will ask you if you have had earaches. It will take about ten minutes.
RISKS, STRESS, AND DISCOMFORT
The needle may hurt you a bit. You might get a bruise.
OTHER INFORMATION
We won't tell anyone you took part in this study. Your name will not be on the sample of blood we take. We will keep the blood for five years. You don't have to take part in this study if you don't want to. No one will be mad at you. We will give you a copy of this paper to keep.
| ________________________________________________ | ____________ | ||||
| Signature of researcher | Date | ||||
| __________________________________________ | |||||
| Printed name of researcher |
Subject's statement:
This research study has been explained to me. I agree to take part in this study. I have had a chance to ask questions. If I have more questions, I can ask the doctor.
| ________________________________________________ | _________________ | ||||
| Signature of subject | Date | ||||
| ________________________________________________ | |||||
| Printed name of subject |