APICHS Survey

APICHS Survey

PLEASE NOTE:  To participate in this research, you must have a child who is between the ages of 2 and 15 AND you must reside in the United States.

PROTOCOL NUMBER AND TITLE OF STUDY: 19-03-1700
NAME OF PERSON IN CHARGE OF THE RESEARCH STUDY: Jessie Hawkins, BA, MA, PhD 
RESEARCH STUDY SPONSOR: Franklin School of Integrative Health Sciences 
TELEPHONE NUMBER(S), DAYTIME: 615-261-3116 AFTER HOURS: 615-642-1919

Thank you for your interest in this study. We are collecting information about the use of personal care products in children and the outcomes children experience. If you decide to participate, you will be taken to a secure, online form. This survey will include questions about your child’s health history and the type of skincare products you have used on your child. You will not be asked to identify your child or provide any details that someone could use to identify your child. It will take between 15 and 20 minutes to complete the survey.

The responses you provide will only be used for scientific research purposes. As a research institution, we are not connected with any health product companies and your information will NOT be shared. Information collected for this study will be used to improve the development of skincare products for children.

You are deciding if you would like to volunteer for a research study. You must read and sign this form before you agree to take part in this study. This form will give you more information about this study.    Please ask as many questions as you need to before you decide if you want to be in the study.  You should not sign this form if you have any questions that have not been answered.

POSSIBLE RISKS & BENEFITS
Your participation in this study does not involve any physical or emotional risk to you beyond that of everyday life. This research will provide information about potential links between personal care products and certain health outcomes in children.

CONFIDENTIALITY 
Your records of being in this study will be kept private except when ordered by law.  The following people will have access to your study records:
• The investigator
• Research institution sponsoring the study
• IntegReview IRB
• Regulatory authorities

CONTACT INFORMATION
If you have questions, concerns, or complaints about this study or to report a study related injury, contact:
Jessie Hawkins, BA, MA, PhD at 615-261-3116 (daytime) OR 615-642-1919 (after-hours)

If you do not want to talk to the investigator or study staff, if you have concerns or complaints about the research, or to ask questions about your rights as a study subject you may contact IntegReview.  IntegReview is a group of people that has reviewed this research study.  The main goal of this review is to protect the rights and well-being of the human subjects participating in research studies. IntegReview’s policy indicates that all concerns/complaints are to be submitted in writing for review at a convened IRB meeting to:
Mailing Address: Chairperson IntegReview IRB3815 S. Capital of Texas Highway Suite 320 Austin, Texas 78704
Email Address: integreview@integreview.com

If you are unable to provide your concerns/complaints in writing or if this is an emergency situation regarding subject safety, contact our office at: 512-326-3001 or toll free at 1-877-562-1589 between 8 a.m. and 5 p.m. Central Time 

IntegReview has approved the information in this consent form and has given approval for the investigator to do the study. This does not mean IntegReview has approved your being in the study.  You must consider the information in this consent form for yourself and decide if you want to be in this study.

VOLUNTEERING TO BE IN THE STUDY
It is your choice if you want to be in the study.  No one can force you to be in the study.  You may not want to be in this study or you may leave the study at any time without penalty or loss of benefits to which you are otherwise entitled. If you leave the study, no more information about you or your child will be collected for this study. However, all of the information you gave us before you left the study will still be used.

By signing this informed consent document, you are acknowledging that you can read, understand, and speak English, that you understand the information in this consent document, and have the opportunity to print a copy of this document for your records. You have had an opportunity to ask questions of study staff and / or a medical professional in a one-on-one setting or by email or phone discussion with the research staff at the contact site above and have received satisfactory answers to all your questions about this study.  You understand that you are free to leave the study at any time without having to give a reason and without affecting your future participation in studies. You understand that your study-related medical records may be reviewed by the Institution sponsoring the study and by government authorities.

IF YOU DO NOT AGREE WITH THE STATEMENT ABOVE, YOU SHOULD NOT SIGN THIS

My return of this survey implies my consent to participate in this research and I have been given a second copy of this form to keep for my records. 

IntegReview approves the use of electronic signatures.
1. ONLINE ACCEPTANCE *This question is required.