Pediatric Research Informed Consent Form
Study Title
Research Team
Introduction
Purpose of the Study
Procedures
Risks and Discomforts
Benefits
Alternative Procedures or Treatments
Confidentiality
Voluntary Participation & Withdrawal
Contact Information
Assent of Child (if appropriate)
Parental/Guardian Permission
Parent/Guardian Name
Signature
Date
Child Name
Signature
Date
Investigator Name
Signature
Date