SAMPLE VIDEO USE CONSENT FORM

for Non-Medical Human Subjects

As part of this research project, we have made a videotape recording of you while you participated in the experiment. We would like you to indicate what uses of this videotape you are willing to consent to by initialing below. You are free to initial any number of spaces from zero to all of the spaces, and your response will in no way affect your credit for participating. We will only use the videotape in ways that you agree to. In any use of this videotape, your name would not be identified. If you do not initial any of the spaces below, the videotape will be destroyed.

(AS APPLICABLE)

  • The videotape can be studied by the research team for use in the research project.

please initial:

____
  • The videotape can be shown to subjects in other experiments.

please initial:

____
  • The videotape can be used for scientific publications.

please initial:

____
  • The videotape can be shown at meetings of scientists interested in the study of emotion.

please initial:

____
  • The videotape can be shown in classrooms to students.

please initial:

____
  • The videotape can be shown in public presentations to nonscientific groups.

please initial:

____
  • The videotape can be used on television and radio.

please initial:

____

FOR QUESTIONS ABOUT THE STUDY

·        Appointment Contact: If you need to change your appointment, please contact (insert name) at (insert phone number).

·        Questions, Concerns, or Complaints: *If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, or alternative courses of treatment, you should ask the Protocol Director.  You may contact him/her now or later at (insert name and phone number of Protocol Director).

·        Emergency Contact: *If you feel you have been hurt by being a part of this study, or need immediate assistance please contact (insert name of Emergency Contact) at (insert Emergency Contact’s phone number) or (if applicable) the Faculty Sponsor, (insert name of Faculty Sponsor) at (insert Faculty Sponsor’s phone number).

·        Alternate Contact If you cannot reach the Protocol Director, please contact (name) at (phone number and/or pager number).

·        Independent of the Research Team Contact: *If you are not satisfied with the manner in which this study is being conducted, or if you have any concerns, complaints, or general questions about the research or your rights as a research study subject, please contact the Stanford Institutional Review Board (IRB) to speak to an informed individual who is independent of the research team at (650)-723-2480 or toll free at 1-866-680-2906.  Or write the Stanford IRB, Administrative Panels Office, Stanford University, Stanford, CA 94305-5401.  In addition, please call the Stanford IRB at (650)-723-2480 or toll free at 1-866-680-2906 if you wish to speak to someone other than the research team or if you cannot reach the research team.

I have read the above description and give my consent for the use of the videotape as indicated above.

(If consent is to be obtained from a legally authorized representative (e.g., parent(s), legal guardian or conservator), signature line(s) for representative must be included on the consent form, as well as a description of his/her authority to act for the subject.)

 

_________________________________      _________________________________

Signature of Legally Authorized Representative   Date

(Parent, Guardian or Conservator)                     

 

_______________________________          _______________________________

Signature of Legally Authorized Representative   Date

(Parent, Guardian or Conservator)         

 

 

_______________________________              _______________________________

Representative's Authority to Act for Subject                 Representative's Authority to Act for Subject

 

 

 

(Special Instructions for obtaining parental consent:  The permission of both parents is required on parental consent documents unless one parent is deceased, unknown, incompetent, or not reasonably available, or only one parent has legal responsibility for the care and custody of the child.  When enrolling a participant, if only one signature is obtained you must check one of the reasons listed below.)

 

The permission of the second parent was not obtained because:

[ ] This parent is deceased

[ ] This parent is unknown

[ ] This parent is incompetent

[ ] This parent is not reasonably available. Explain: ___________________________________________________________

[ ] The first parent has legal responsibility for the care and custody of the child

 

The extra copy of this consent form is for you to keep.

SIGNATURE _____________________________ DATE ____________

Protocol Approval Date: _______________________
Protocol Expiration Date: ________________________