Parental or Guardian's Consent for Child to Participate in Research by wuzhenguang


									C                                              Sample C

                            Consent to Participate in Research Project:
        Using Assistive Technology to Increase Expressive Language for Two Kindergarteners

    Use this type of PARENTAL/GUARDIAN CONSENT FORM for research projects that

        Participants who are MINORS = (Children under the age of 7 are not required to sign an
         assent form)

        Intervention (educational, at school)

        Small-N, single-case/applied behavior analysis research methods/design

        Researcher has pre-existing relationship with participants (e.g., researcher is a teacher
         and the participants are that teacher's students; researcher is a service provider and the
         participants are that service provider's current or prospective clients)

                          See Sample C Consent Form on Following Pages

C                                          University of Hawai'i

           Parental or Guardian's Consent for Child to Participate in Research Project:
         Using Assistive Technology to Increase Expressive Language for Two Kindergarteners

    Aloha (Mr./Mrs.Ms. ____). I am, Kalani Researcher, your child’s teacher at Hoku Elementary
    School. I also am a graduate student at the University of Hawai’i, in the Department of Special
    Education. One requirement for earning my Master's degree is to do a research project. The
    purpose of my research project is to determine if using a new assistive technology device (that is,
    an electronic push-to-talk device), during recess, increases expressive language of two nonverbal
    elementary students who communicate currently using a non-electronic picture communication

    I am asking your permission for your child to participate in this project because [NAME] is one
    of two of my students who currently use a non-electronic communication board, and (he or she)
    might benefit from using the electronic push-to-talk device. You, as (his or her) parents, and I, as
    (his or her) teacher, have been concerned that this board limits [NAME's] communication,
    particularly with kindergarten classmates. I also will ask [NAME] if (he or she) agrees to
    participate in this project.

    Project Description - Activities and Time Commitment: If your child participates in this
    project, here’s what [NAME] and I will do and how long it will take.

       1. First, I will observe [NAME] for 20 minutes, during the kindergarten morning recess
          period, for about 3 to 5 consecutive recess periods. I will count the number of
          occurrences of expressive language (how many times [NAME] uses his communication
          board to express himself to a peer or teacher) during these 20-minute recess periods.

       2. Next, during the course of one day, I will teach [NAME] how to use the new device by
          having him/her practice first with me, then with a few classmates, during the morning
          recess periods. These training sessions will last about 5 minutes each, and will occur 4
          times during morning recess, for a total of 20 minutes training time.

       3. Next, the day after training, I will observe [NAME] at morning recess, and I will again
          count the number of occurrences of expressive language (how many times [NAME] uses
          (his or her) new electronic push-to-talk device) to express (himself or herself) to a peer or
          teacher, during the 20-minute recess period. I will continue to observe and collect this
          data for about 8 to 10 consecutive days during morning recess.

    Benefits and Risks: I believe that [NAME] may directly benefit by participating in this study.
    That is, based on research and my colleagues' experiences using this push-to-talk device with
    children who previously communicate mostly by nonverbal means, I believe that [NAME] may
    communicate more frequently with his classmate while at recess. More generally, when I report
    the results of this intervention study, the results could contribute to research findings about this
    topic, and it could promote more widespread use of these types of devices.

I believe there is little to no risk in [NAME] participating in this research study. (He or She)
might, however, be a little uncomfortable with using this new device. To minimize this risk, I
will ensure that [NAME] easily uses the device when I train him, keeping errors to a minimum.
If [NAME] were to become too stressed or uncomfortable, I will ask his if he would like to take
a break from the training, or do the training at another time or location. If stress persists, then I
will discontinue the training and contact you to discuss whether we should stop NAME's
participation in this research project.

Confidentiality and Privacy: During this project, only my University of Hawaii advisor and I
will have access to the data, although legally authorized agencies have the right to review
research records. When I report the results of my research project, I will not use your child's
name or any other personally identifying information. Instead, I will use a pseudonym (fake
name) for your child. If you would like a summary of my final report, please contact me at the
number listed near the end of this consent form.

Voluntary Participation: NAME’s participation in this project in voluntary, and so is your
decision about permitting or not permitting (him or her) to participate. Moreover, at any time,
NAME can stop participating in this project and you can withdraw your consent without any loss
of benefits or rights.

I realize that I am both the researcher, and at the same time, NAME's teacher. Thus, I want to
assure you that the choice to participate or not participate in this project will have no impact on
NAME’s report card or on my relationship with NAME as (his or her) teacher.

If you have any questions about this project, please contact me at (808) 555-3333 or You can also contact my University of Hawai’i [supervisor/advisor], Dr.
Advisor at (808) 956-0000 or If you have any questions about your rights
or the rights of your child in this research project, you can contact the University of Hawai‘i,
Committee on Human Studies (CHS) by phone at (808) 956-5007 or by e-mail at

               Please keep the prior portion of this consent form for your records.

If you agree for your child to participate in this study, please sign the following signature portion
                             of this consent form and return it to ***.

Signature(s) for Consent:

I give permission for my child to participate in the research project entitled, Using Assistive
Technology to Increase Expressive Language for Two Kindergarteners. I understand that, in
order to participate in this project, my child must also agree to participate. I understand that my
child and/or I can change our minds about participating, at any time, by notifying the researcher
to end participation in this project.

Name of Child (Print): ___________________________________________________

Name of Parent/Guardian (Print): _________________________________________

Parent's/Guardian's Signature: _____________________________________________

Date: ____________________________


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