The University of Arizona

Consent Templates

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HSPP Contacts

Department email:
VPR-IRB@email.arizona.edu

*Subscribe to the HSPP listserv

Mariette Marsh, Director
(520) 626-7575

Christine Melton-Lopez, Assistant Director 
(520) 626-8630

Mason Burchfield, IRB Coordinator
(520) 626-0433

Gina Fimbres, IRB Coordinator
(520) 626-0026

Jessica Winters, IRB Coordinator
(520) 626-0256

Alyssa Little, IRB Associate
(520) 626-5859

Jared Pryor, IRB Associate
(520) 626-1744

Jeff Homes, IRB Associate

(520) 626-7889

Joanna Schrader, IRB Associate

(520) 626-6282

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Social/Behavioral Consents

Federally funded - Social/Behavioral Informed Consent (v. Feb 2019) (Word)
This consent template is for non-medical research that is funded or supported by a federal agency. This consent should be used to obtain permission from subjects to participate in research being conducted by the University of Arizona. This consent template is required.

Non-Federally funded - Social/Behavioral Informed Consent (v. Feb 2019) (Word)
This consent template is for non-medical research that is NOT funded or supported by a federal agency. This consent should be used to obtain permission from subjects to participate in research being conducted by the University of Arizona. This consent template is recommended, but not required. If this consent template is not going to be used, please develop a consent form that addresses the required elements of consent.

Medical Consents

University of Arizona Medical Consent Form (v. July 2019) (Word)
This consent template is required for any research medical research. If research is occurring at Banner– University Medical Centers Tucson, South or Phoenix campuses please include the grey language within the document and the Banner-UA logo. The template combines informed consent and Protected Health Information (PHI) required language. This consent template is required

Additional Consent Templates

Consent Addendum (version 2016-07) (Word)
This consent addendum template should be used when there is a new portion of a research project that requires a participants’ signature. This template is recommended, but not required.

Stand-alone Banner HIPAA Authorization

Stand-alone Banner HIPAA Spanish Authorization  (Certificate of Translation)

National Cancer Institute Consent Form

National Cancer Institute; Cancer Therapy Evaluation Program forms

National Heart, Lung and Blood Institute Consent Template

National Institute on Aging (NIA) Consent Form Template

Office of Biotechnology Activities

World Health Organization Templates

GDPR Consent Addendum

Using the Short Consent Form

Short Consent Form (from the University of Minnesota)
Consent form in English, Spanish, and other languages.

Instructions for using the Short Form

What is a short form?
A short form is a written document stating that the elements of informed consent required by 45 CFR 46.116 have been presented to the subject or the subject's legally authorized representative.

When can a short form be used?
A short form can be used when the majority of subjects are English-speaking, but a small portion of the sample population is expected to prefer the consent process to be conducted in another language. Use of the short form to obtain consent ensures equal access for potential participants.

If the majority of the anticipated subjects to be enrolled do not speak English or will be unable to understand the consent form written in English, the consent form must be translated into a language understandable to the subjects.

How to use short forms
A short form must be used in conjunction with an oral presentation of the consent information required by 45 CFR 46.116. A summary of what will be said to the subject or representative must be approved by the IRB and then presented orally to the subject or representative in front of a witness. A copy of the short form and a copy of the summary must be given to the subject or representative.

Required signatures with short forms

  • Short Form - Subject/Representative and the Witness
  • Copy of Summary - Witness and Person obtaining consent

What must be approved by the IRB?
Use of a short form must be reviewed by the IRB prior to use. Amendment for Approved Human Research should be submitted to the IRB with the following information:

  1. Justification for the use of the short form.
  2. Summary of what will be presented to the subject or representative (this can be the English version of the informed consent document).
  3. Text of short form or assurance that University of Minnesota IRB Short Forms will be used.

After a short form has been used with a subject submit the Amendment for Approved Human Research and use the Notify IRB section. This information is also reportable on the Renewal Progress Report. 

HIPAA Authorization and the Short Form Process

How is Protected Health Information (PHI) Authorization obtained when a short form process is used?

There is no short form process for obtaining PHI Authorization. A full PHI Authorization must be translated and used in addition to the IRB approved short form consent process. 

 If a fully translated HIPAA authorization will not be provided during the short form process, the project must have an approved waiver of PHI authorization on file.