Consent Form for IRB-FY2016-650
New York University
A private university in the public service
Dr. Wendy Suzuki
Center for Neural Science
New York University
4 Washington Place, Room 809
New York, NY 10003
Phone: (212) 998-3734
Fax: (212) 995-4011
Informed Consent Form
You have been invited to take part in a pilot research study about cognition and mood.
We’re gathering data about performance on cognitive tasks among different groups of people.
The Principal Investigator for this study is Dr. Wendy A. Suzuki at the Center for Neural Science, New York University.
If you agree to be a participant, you will be asked to do the following:
Provide your name and e-mail address.
Answer a few questions regarding your gender, race, ethnicity, education, health status, and exercise regimen.
Take several cognitive and mood tasks
Participation in this study will require approximately 30 minutes of your time in total.
There are no known risks associated with your participation in this research.
This research may help the investigator understand the effects of exercise on brain health and functioning.
Federal regulations require that all subjects be informed of the availability of medical treatment or
financial compensation in the event of physical injury resulting from participation in the research.
New York University cannot provide either medical treatment or financial compensation for any physical
injury resulting from your participation in this research project. If physical injury does occur, as with
any gymnasium or health club, medical services will be provided at your own expense. You do not give up any
legal rights to seek payment for personal injury by consenting to this research.
Confidentiality of your research records will be strictly maintained by assigning code numbers to each
participant so that data is never directly linked to individual identity. All completed materials will be
kept in a secured server within the Suzuki lab only accessible to the investigator. We cannot keep information
confidential if we have concerns that someone is harming children. In such cases, we will inform people in
authority about our concerns. Information not containing identifiers may be used in future research or shared
with other researchers without your additional consent.
Participation in this study is voluntary. You may refuse to participate or withdraw at any time without penalty.
For interviews, questionnaires, or surveys, you have the right to skip or not answer any questions you prefer not to answer.
If there is anything about the study or your participation that is unclear or that you do not understand,
if you have questions or wish to report a research-related problem, you may contact DJ Oberlin at email@example.com or
Wendy Suzuki at firstname.lastname@example.org and (212) 998-3969.
For questions about your rights as a research participant, you may contact the University Committee on Activities
Involving Human Subjects, New York University at 665 Broadway, Suite 804, New York, New York,
10012 - email@example.com or (212) 998-4808.
You have received a copy of this consent document to keep.