Printable Format 

Sample Consent Form

**This form should be adapted to your project and should include information about the general nature of the study and the procedures that will be used. Also, the name of the researcher and status (i.e. graduate student in     dept) and the name of the advisor should be included on the form. *** Be sure to see “Other considerations” below.

Anyone signing a Consent Form should be given a copy of their signed form.

CONSENT FORM

            The signing of this form constitutes consent to participate in the                           study being conducted by                                  who is a                                   (state if grad or undergrad & in what dept) working under the supervision of                                     . The purpose of this study is to …. (describe general nature and procedures). I understand that my participation in this study is entirely voluntary and that I will be video/audio taped (if applicable). The procedures being used to ensure confidentiality are ….(see *3 below).  Explain how confidentiality will be maintained (i.e. if coding will be used for names and data) and state that names and data will be stored separately.  Explain how the data will be stored and the disposition of it.  Example:  The research material will be kept in a locked file cabinet in my advisor's office.  (material can not be stored in an undergraduates residence).  The audio/video tapes will be erased/deleted after the study is completed.   Participation in this study should take approximately ______ minutes for the (questionnaires/interviews/ surveys) to be completed.  Further, I am aware that I am free to terminate my participation in this research at any time, or to refuse to answer any questions to which I don’t want to respond.

                        (Signature)                                                        (Date)

Other Considerations:

* If using students in class as subjects or if using medical patients, you must state that participating or not participating will not affect their standing in class or their medical treatment, whichever is appropriate.

*If audio or video taping is used, the Consent Form or Statement of Rights must state “I give permission” or “I understand that video/ audio taping will be used.”

*When ensuring confidentiality, you should state that material will be kept in a locked file cabinet only available to researchers, by using coding for names, or similar methods that would assure confidentiality.

*All surveys or questionnaires on the Clark web site must be set up by Clark’s ITS (Information Technology Services) office to ensure anonymity.

Anonymous or Confidential

Anonymous- No obvious or easy way to identify participants (a face-to-face encounter can not be anonymous).

Confidential- keeping secure from scrutiny of others, although the identity of the person may be known.