Study Title:  	MyStudy 

Principal Investigator:  	Name	Address
 	phone:
 	email:
 _______________________________________________________________________________
                                                                                                                                           
Purpose of this Study:
The purpose of the study is to gather data to be placed in a computerized data bank for the study of language and communication in (specify topic area here). Researchers will be able to access these data over the Internet.

Procedures:
(Describe and list procedures here). The session will be videotaped (or audiotaped) for later transcription and analysis. In addition, you will be asked to provide relevant demographic information. The research will be take approximately (specify duration) 
of your time and will be done at (specify location).

Participant Characteristics:
Participants in this study should be (specify conditions for participation, 
such as normal hearing, children learning English, or children aged 2-4)

Risks:
The risks and discomfort associated with participation in this study are no greater than those ordinarily encountered in daily life or during normal conversation, which may include frustration, fatigue, and/or boredom.  

Benefits:
There is no clear personal benefit for you or your child for participation in this study.  

Compensation and Costs:
You will receive $40 as well as free parking during testing.  There will be no cost to you for participating in this study.

Confidentiality: To maintain confidentiality, your data and consent form will be kept separate. The consent form will be kept in a locked file.  All references to your last name or address will be removed from the transcripts and recordings of the session. Your name, address, contact information and other direct personal identifiers in your consent form will not be mentioned in any such publication or dissemination of the research data. 

By participating, you understand and agree that the data and information gathered during this study may be used by qualified researchers.  (The following is only necessary, if password protection is required:) Access to the data will be limited by passwords that are only provided to qualified researchers.

Rights:
Your participation is voluntary.  You are free to stop participation at any point.  Refusal to participate or withdrawal of your consent or discontinued participation in the study will not result in any penalty or loss of benefits or rights to which you might otherwise be entitled. You also have the right at any time to have your data removed from the database.

Right to Ask Questions and Contact Information:
If you have any questions about this study, you should feel free to ask them now. If you have questions later, desire additional information, or wish to withdraw your participation please contact the Principle Investigator by mail, phone or e-mail in accordance with the contact information listed on the first page of this consent.  

If you have questions pertaining to your rights as a research participant; or to report objections to this study, you should contact the Research Regulatory Compliance Office at Carnegie Mellon University.  Email:  HYPERLINK "mailto:irb-review@andrew.cmu.edu" irb-review@andrew.cmu.edu . Phone: 412-268-1901 or 412-268-5460.

Voluntary Consent:

By signing below, you agree that the above information has been explained to you and all your current questions have been answered.  You understand that you may ask questions about any aspect of this research study during the course of the study and in the future.  By signing this form, you agree to participate in this research study. 

Signature   _______________      Date:   ______________________