Informed Consent for Pediatric Research Participants

Study Title

Principal Investigator

Purpose of the Study

Procedures and What Will Happen

Risks and Discomforts

Benefits

Confidentiality

Cost and Compensation

Voluntary Participation and Withdrawal

Contact for Questions

Parental/Guardian Consent

Child's Name
Date of Birth
Parent/Guardian Name
Parent/Guardian Signature
Date

Investigator Statement

Investigator Name
Signature
Date