被试知情同意书

协议题目

Protocol Title

*****研究

Studies of ******

主要研究者Principal/Overall Investigator

****，教授

****研究所，*****实验室

合作研究者 Co-Investigator(s)/Study Stuff

****研究所，*****实验室

被试类型

(Subject Population)

项目联系人和地址

(Study Contact)

联系电话

Telephone

电子邮箱

Email

研究目的(Purpose)

       你现在自愿参加的是一个关于*********的实验。我们希望您能够同意参加本项研究。(You have been asked to participate in a research study that focuses on ******. We would like your permission to enroll you as a participant in this research study.)

实验程序(Procedure)

对实验的方法和持续时间（包括有无录音录像）加以简单描述。(英文)

费用(Costs)

       本研究不会向您收取任何费用。(No charges will be billed to you for this study.)

潜在风险和副作用(Risks and Discomforts)

受益(Benefits)

       虽然您参加本研究对您本人并不带来别的直接利益，但这个项目的研究将可能带来*****益处。(There is no other direct benefit of your participation in this experiment. However, research in this area may eventually be helpful for *****.)

鉴于参加本研究给您带来了一定程度的不便，因此我们会为您支付车费和误工费，每次****元。（注意：本条为可选项）

另外，本研究将向您提供相应的数据反馈。（注意：本条为可选项）

隐私(Confidentiality)

       本研究的结果可能会在学术期刊/书籍上发表，或者用于教学。但是您的名字或者其他可以确认您的信息将不会在任何发表或教学的材料中出现，除非得到您的允许。 (The results of this study may be published in an academic journal/book or used for teaching purposes. However, your name or other identifiers will not be used in any publication or teaching materials without your specific permission.)

受伤声明(Injury Statement) [注意：本声明为可有可无的选择项，在有些类型的研究中不必出现]

       如果您在本研究过程中受伤且受伤是研究程序的直接结果，您应当与主要研究者取得联系，并且您将得到必要的治疗。但是，这个治疗并不表明是本实验室或者主试的过失导致您的受伤。本实验室或者主试也不将提供其他补偿。(If you are injured during the course of the study and as a direct result of this study, you should contact the investigator at the number provided. You will be offered the necessary care to treat that injury. This care does not imply any fault or wrong-doing on the part of the lab or the experimenter(s) involved. The lab or the experimenter(s) will not provide you with any additional compensation for such injuries.)

实验终止（withdraw from the research）

您的参与完全基于自愿的原则，您可以在实验的任何过程中要求退出，并且您不会因为退出实验而受到处罚或损失。(Participation is voluntary, refusal to take part in the study involves no penalty or loss of benefits to which participants are otherwise entitled, and participants may withdraw from the study at any time without penalty or loss of benefits to which they are otherwise entitled.)

主试声明(Experimenter)

       我已经解释了研究的目的，研究的程序，潜在的危险和不舒适以及被试的权益，并尽最大可能回答了与研究有关的问题(I have explained the purpose of the research, the study procedures, identifying those that are investigational, the possible risks and discomforts as well as potential benefits and have answered any questions regarding the study to the best of my ability)

签名(Signature):　   　　　日期(Date):       

被试(subject)

       我声明我已经被告知本研究的目的、过程、可能的危险和副作用以及潜在的获益和费用。我的所有问题都得到满意的回答。我已经详细阅读了本被试同意书。我下面的签名表明我愿意参加本研究。(I confirm that the purpose of the research, the study procedures and the possible risks and discomforts as well as potential benefits that I may experience have been explained to me. All my questions have been satisfactorily answered. I have read this consent form. My signature below indicates my willingness to participate in this study)

签名(Signature):　    　　　日期(Date):

l       你是否愿意接收上海师范大学ERP中心的被试招募信息？(Would you like to receive subject recruiting?)  是 （Yes）       否（No）      。

l       如果回答愿意，请留下您的联系方式（If yes, please leave your contact information）：

电子邮件（EMAIL）                      ，电话（Telephone）                   。