Exhibit G: Example Parental Permission Letter

December 4, 2004
Dear Parent or Guardian:
I am May Flower, a doctoral student of Dr. Justin Time from the Philosophy Department at Michigan
Technological University. I request permission for your child to participate in a research study to be used
for my doctoral dissertation. I am conducting a research project on how well the Transitional Living
Program helps children with physical disabilities learn everyday skills.
We hope to use what we learn from the study to make changes to the program so it will help people with
physical disabilities even more than the program already does.
The study consists of the following activities:
1. We will ask your permission for your child to take part in 2 to 4 tasks over the course of a total of
about 3 weeks. Each task will last about 30 minutes to 1 hour.
2. These tasks may include: (1) answering questions about what your child has learned while in the
program, how your child feels about being in the program, and your childs behavior; and (3) taking
short quizzes on things your child has learned in the program.
3. Sometimes the researchers will observe your child while he or she takes part in activities at the center.
4. Some activities may be videotaped. The videorecorder will be placed in the corner of the day room
and will be operated by one of the researchers.
5. We will ask your permission to obtain a list of medications (and dosages) your child is currently
taking while in the Transitional Living Program. We will not access your childs medical records.
The project will be explained in terms that your child can understand, and your child will participate only
if he or she is willing to do so.
Only Dr. Time and I will have access to information from your child. At the conclusion of the study,
childrens responses will be reported as group results only. At the conclusion of the study a summary of
group results will be made available to all interested parents. Please indicate at the end of this consent
form whether you wish to have these results. If so, please provide your mailing address. If you do not
wish to provide your mailing address, you may obtain the results from the Internet at xxx.indusrelisu.edu.
Results should be available in approximately 12 months.
Participation in this study is voluntary. Your decision whether or not to allow your child to participate will
not affect the services normally provided to your child by the Transitional Living Program and your child
will lose no benefits to which he or she is otherwise entitled. Even if you give your permission for your
child to participate, your child is free to refuse to participate. If your child agrees to participate, he or she
Date of IRB Approval: November 1, 2004
IRB Number:
M000
Project Expiration Date: October 31, 2005

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is free to end participation at any time. You and your child are not waiving any legal claims, rights, or
remedies because of your childs participation in this research study.
Should you have any questions or desire further information, please feel free to contact
Ms. May Flower
Principal Investigator
Department of Philosophy
Michigan Technological University
Houghton, MI 49931
906-555-4444
mflower@mtu.edu

Dr. Justin Time

Associate Professor
Department of Philosophy
Michigan Technological University
Houghton, MI 49931
906-555-5555
justintime@mtu.edu

Keep this letter after completing and returning the signature page to me.
If you have any questions about your rights as a research subject, you may contact
the Michigan Technological University Institutional Review Board (IRB) by mail at
1400 Townsend Drive, Houghton, MI 49931, by phone at (908) 487-2902, or by email at jpolzien@mtu.edu. Thisstudy(IRB#M000)wasapprovedbytheIRBonJuly1,2004.
Sincerely,

May Flower
Department of Philosophy

Date of IRB Approval: November 1, 2004

IRB Number:
M000
Project Expiration Date: October 31, 2005

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-----------------------------------------------------------------------------------------------------------------------------Please indicate whether or not you wish to allow your child to participate in this project by checking one
of the statements below, signing your name and returning it to me. Sign both copies and keep one for your
records.
_____ I do grant permission for my child to participate in Ms. May Flowers study of the Transitional
Living Program.
_____ I do not grant permission for my child to participate in Ms. May Flowers study of the
Transitional Living Program.

______________________________
Signature of Parent/Guardian

_______________________________
Printed Parent/Guardian Name

______________________________
Printed Name of Child

_______________________________
Date

_____ Yes, I would like a copy of the results of this study. My mailing address is below.

Date of IRB Approval: November 1, 2004

IRB Number:
M000
Project Expiration Date: October 31, 2005

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