IRB Administration Approved, Standard Consent Form for Exempt Research

 

CONSENT TO ACT AS A HUMAN RESEARCH SUBJECT

UNIVERSITY OF CALIFORNIA IRVINE

 

 

Survey of Travel Behavior Changes Associated with a Shared-use Electric Vehicle Pilot Program

 

TITLE OF STUDY

 

Michael G. McNally, Institute of Transportation Studies, 824-8462,

 

NAME, DEPARTMENT AND TELEPHONE NUMBER OF INVESTIGATOR

 

You have been asked to participate in a research study which is exempt from review by an Institutional Review Board.  The purpose of the study, terms of your participation, as well as any expected risks and benefits, must be fully explained to you before you sign this form and give your consent to participate.

 

You should also know that participation in research is entirely voluntary. You may refuse to participate, or may withdraw from participation at any time without jeopardy to future medical care, education or employment status, or other entitlement.  However, by voluntarily refusing or withdrawing from the survey, you renounce your right of participating in the e.com program.

 

The investigator may withdraw you from participation at his/her professional discretion.

 

If, during the course of this study, significant new information which has been developed during the study becomes available, which may relate to your willingness to continue to participate, this information will be provided to you by the investigator.

 

Any information derived from this research project which personally identifies you will not be voluntarily released or disclosed without your separate consent, except as specifically required by law.

 

If at any time you have questions regarding this research or your participation in it, you should contact the investigator or his/her assistants who must answer your questions.

 

If, at any time, you have comments regarding the conduct of this research or if you wish to discuss your rights as a research subject, you may contact the Office of Research Administration at (949) 824-6068 or (949) 824-2125. 

 

You will be given a copy of this consent form to keep.

 

I consent to participate in this study.

 

 

     

 

SIGNATURE OF SUBJECT (Age 7 and older*)                                                                                  DATE

 

 

 

     

 

*SIGNATURE OF PARENT/GUARDIAN (if subject is under 18)                                                    DATE

 

 

 

     

 

SIGNATURE OF INVESTIGATOR                                                                                                    DATE

 

THIS FORM IS FOR USE WITH EXEMPT RESEARCH ONLY