“People Who Self-Injure” Principal Investigator, name PARENTAL

“People Who Self-Injure”
Principal Investigator, name
PARENTAL CONSENT FORM
date
Please read the following material that explains the research study in which your child is being asked
to participate. Signing this form will indicate that you have been informed about the study and that
you give permission for your child to participate. I want you to understand what your child is being
asked to do and what risks and benefits, if any, are associated with the study.
Once you provide your permission, your child will also be asked to provide his or her assent to
participate. Your child may not participate in the study unless BOTH you and your child agree.
I, name, am a faculty member at the school. I would appreciate your helping me out in my study on
people who cut themselves. If you ever want to contact me about my study, you may reach me at the
school address, school phone number. Another excellent way to contact me is by email at: my email
address.
Project Description: I am interested in learning more about the phenomenon of people who cut
themselves. I would like to know more about why people do this, how it feels at the time, and how it
affects them subsequently. In particular I am curious to know how people come to do this, if there is a
subculture that supports it, why this gives some people a sense of relief, and how they then have to
manage the information about this behavior with others. I would like to know how it affects them when
they reveal this information to others or when others find out about it.
Procedures: I would like to talk to your child about this and to tape-record our conversation. I hope you
will permit your child to share some of his or her experiences and thoughts with me on this matter.
Depending on how much he or she has to say, our conversation is most likely to take anywhere from 45
minutes to two hours. Together we can arrange a mutually convenient time for us to talk. If we are in the
same town, he or she and I can meet in my office where we can chat in privacy and without interruption.
If you live far away from me, your child and I can conduct our conversation on the telephone, if that is
okay with you.
Risks and Benefits: There are some potential risks your child may encounter from doing this interview.
Your child may talk about things that stress him or her. Your child may find discussing the self-injury a
sensitive and emotional subject. We may venture into difficulties your child has in managing his or her
behavior with others and his or her feelings about that. Your child may worry that I will judge him or her
or think less of him or her for this practice. Please be assured that this is not the case. Your child’s
behavior, while non-conformist, is not illegal or immoral. My goal is to understand this behavior, not to
judge anyone. If your child feels that he or she need further help, I am happy to help him or her find
someone good to talk to in your area. I have a list of counselors in Boulder specifically trained to deal
with this topic that I am happy to share with your child. If there are any subjects your child would prefer
not to talk about, he or she can just say so and we can go on to another subject. Everything that your child
says will be held in the strictest confidence. There will be no compensation, nor will there be any costs
incurred (including long distance telephone charges), for this interview.
Initial ____________________
Study Withdrawal: If you decide to let your child participate in this project, please understand that this
participation is voluntary and that your child has the right to withdraw consent or to discontinue
participation at any time. Your child has the right to refuse to answer any question(s) for any reason.
Confidentiality: In addition, I will maintain the privacy of the experiences your child discusses in all
published and written data resulting from this study. Sociologists are interested in trends and patterns of
behavior rather than individual accounts, and I will use pseudonyms to disguise the identity of my
subjects as a confidentiality measure.
I will be tape recording our conversations so that I can remember most accurately what your child has
said. Please be assured that I will keep these data in the most secure location, locked in my office, and
that they will be destroyed when I have finished with this research. I will shred my notes, and erase over
any tapes with a demagnetizer.
Invitation for Questions: If you or your child have any questions about this study, you should ask me
them before you sign this permission form. If you have any questions regarding your child’s rights as a
subject, any concerns regarding this project, or any dissatisfaction with any aspect of this study, you may
report them – confidentially, if you wish, -- to the IRB administrator, or by telephone to phone #. Copies
of the school Assurance Of Compliance to the federal government regarding human subject research are
available upon request from the Graduate School address listed above.
I have read this paper about the study or it was read to me. I know the possible risks and benefits. I
know being in this study is voluntary and that my child has the right to decline to participate or to
withdraw his or her assent at any time during the study. I give permission for my child to be in this
study. I have received, on the date signed, a copy of this document containing 2 pages.
Name of Participant (printed) ______________________________________________
Name of Parent or guardian (printed) ________________________________________
Signature of Parent or guardian _____________________________ Date ___________
(Please also initial all previous pages of the permission form)
For HRC Use Only
This permission form is approved for use from _________________ to ________________.
_________________________________ Executive Secretary, Human Research Committee
(Signature)