CONSENT TO PARTICIPATE IN RESEARCH
The Effects of Added Sugar
You are invited to participate in a research study conducted by Ms. Alex Curtis and Dr. Karla Kennedy-Hagan (and faculty sponsor if the PI is a student), from the Family and Consumer Sciences Department at Eastern Illinois University.
Your participation in this study is entirely voluntary. Please ask questions about anything you do not understand, before deciding whether or not to participate.
PURPOSE OF THE STUDY
To find the effects of eliminating added sugar from the diet.
If you volunteer to participate in this study, you will be asked to:
Eliminate added sugar from your diet for 21 days and record any changes you notice before, during, and after this time. Added sugar includes any of the following names:
Cane juice crystals
Corn syrup solids
Evaporated cane juice
High-fructose corn Syrup
Organic raw sugar
We also ask you to not use any sugar substitutes like sweet ‘n low, splenda, etc.
You will be asked to complete a short survey before and after the 21 days.
POTENTIAL RISKS AND DISCOMFORTS
Risks are relatively low because added sugar is not a necessity in the diet. You may, however, experience tiredness, headaches, or moodiness.
POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
Potential benefits include increased energy, less cravings, and weight loss.
Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. Confidentiality will be maintained by means of not including any identifiable questions like name or location.
PARTICIPATION AND WITHDRAWAL
Participation in this research study is voluntary and not a requirement or a condition for being the recipient of benefits or services from Eastern Illinois University or any other organization sponsoring the research project. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind or loss of benefits or services to which you are otherwise entitled.
There is no penalty if you withdraw from the study and you will not lose any benefits to which you are otherwise entitled.
IDENTIFICATION OF INVESTIGATORS
If you have any questions or concerns about this research, please contact:
Alex Curtis at firstname.lastname@example.org
RIGHTS OF RESEARCH SUBJECTS
If you have any questions or concerns about the treatment of human participants in this study, you may call or write:
Institutional Review Board
Eastern Illinois University
600 Lincoln Ave.
Charleston, IL 61920
Telephone: (217) 581-8576
You will be given the opportunity to discuss any questions about your rights as a research subject with a member of the IRB. The IRB is an independent committee composed of members of the University community, as well as lay members of the community not connected with EIU. The IRB has reviewed and approved this study.
I voluntarily agree to participate in this study. I understand that I am free to withdraw my consent and discontinue my participation at any time. I have been given a copy of this form.
Printed Name of Participant
Signature of Participant Date
NOTE: Use the following signature line for minor/handicapped subjects only if applicable.
I hereby consent to the participation of _____________________________________________, a minor/subject in the investigation herein described. I understand that I am free to withdraw my consent and discontinue my child’s participation at any time.
Signature of Minor/Handicapped Subject’s Parent or Guardian Date
I, the undersigned, have defined and fully explained the investigation to the above subject.
Signature of Investigator Date