Three Sample Informed Consent Forms
INFORMED CONSENT FORM
QUESTIONNAIRE ON RECYCLING ATTITUDES AND BEHAVI0RS
We are conducting a survey on environmental awareness and recycling at College. Your voluntary participation is requested so we may learn more about the attitudes and behaviors regarding municipal waste recycling. Our questionnaire will take approximately 5 minutes. Your name will not be recorded on the questionnaire and your responses will be anonymous. Again, your participation is voluntary and you may choose to not answer all of the questions on the questionnaire even after signing the consent. If you are willing to participate, please sign this form.
If you have any questions pertaining to this study, please contact Dr. Z, Department of X, College, Telephone #.
Thank you for your assistance.
Participant Signature
_______________________________________
Date
___________________
Informed Consent Form
A Study of Academic Identification and Self-Concept Among African-American Students
I have been recruited to participate in a study of academic identification and self-concept. If I consent to participate in this study I will complete a series of questionnaires. These include measures of attitudes about my racial identity, self-concept, academic identification, the importance of various group memberships, and a background questionnaire. The time to complete these questionnaires should be about one hour. I understand that I will receive $10.00 for agreeing to participate in this study. I will also be asked to consent to allowing the researchers access to my academic records.
Beyond payment for my participation it is unlikely that I will directly benefit from my participation in this study. However, the knowledge gained from this study may contribute to understanding factors that affect the academic success of African-American college students. All individual research results will be kept confidential. Results will only be reported in group form and I will be provided with a group summary of the results on request.
There are no predictable physical ill effects associated with participating in this study. Answering some questions about self-concept and racial or academic identity might create transitory discomfort. I understand that I am completely free to refuse to answer any question without penalty. If participating in this study causes any problems, such as anxiety created by answering personal questions I will be referred to Dr. X for evaluation counseling, or referral to professional assistance. Dr. X can be contacted in Room Z of College.
I understand that I may refuse to participate in this study and am free to cease participating at any time after the study has started. If I stop I will not be penalized and will receive a $10.00 payment for participation. I also understand that I may be contacted in the future to participate in similar studies. If you wish to obtain information about the outcome of the study it can be obtained from or withdraw consent to allow us to gather information about your grades and academic records, please contact:
Dr. X
Associate Professor
College
Telephone #
I have read and understood this consent form, and I agree to participate in this study.
|
______________________________________ |
______________________________________ |
|
Signature |
Date |
|
______________________________________ |
______________________________________ |
|
Printed Name |
Witness |
To enable us to contact you in the future please provide the following information.
______________________________________________________________________
Local Address
INFORMED CONSENT FORM
The purpose of this form is to provide a clear explanation of the nature of this study. The necessary procedures are described below. If, after reading this form, you have any questions or concerns, please discuss these with Dr. X, supervisor of this project. Name can be reached at the telephone number at any time prior to, during, or after your participation is completed. Once you are entirely satisfied with this explanation and freely choose to participate in the study, you may indicate your willingness to participate by signing below. Your are free to end your participation in the study at any time.
In this study, the relationship between several personality characteristics and cardiovascular responding (i.e. heart rate, systolic blood pressure and diastolic blood pressure) to challenging tasks will be assessed in African American men and women. This investigation seeks to determine whether personality questionnaires are good at predicting responses to challenging tasks, and also seeks to understand the relationship between coping strategies and cardiovascular reactivity,
The study will be broken into two sessions and will take about 90 minutes to complete. During one of the sessions you will complete several forms that measure attitudes and personality characteristics. one of the sessions, you will complete several forms that measure attitudes and personality characteristic. Completion of this session will take approximately thirty minutes.
During the other session, your cardiovascular reactivity will be measured by placing a single finger cuff on the index finger of your hand. While you are sitting, your heart rate, systolic and diastolic blood pressure measurements will be taken and you will be asked to complete three tasks: 1) to figure a math problem, 2) to identify a small figure in a series of larger figures, and 3) to identify a simple figure in other figures presented immediately afterwards. At the end of this session, you will be asked to talk about the approach you used in completing the three tasks. This session will take approximately one hour to complete.
All of the forms that you complete, and the records of your heart rate, systolic and diastolic blood pressure are completely confidential. You are asked not to write your name on any of the questionnaire You will not be identified by name on any of these forms, only by a special number code. Your records will be kept locked in a filing cabinet. Your results will be combined with those of other participants and they will be studied only in this fashion.
There is no risk of physical injury from participation in this study. However, participants may become more aware of their own personal feelings and beliefs by answering questions. If you decide that you do not wish to participate in the study after it has started, please tell Name or the research assistant. There is no penalty imposed if you decide to end your participation early. You will be provided with $15.00 for your participation in the study.
I understand that the procedures involved in this study involve minimal risks. With this in mind and with the above description of the project, I voluntarily agree to take part in the study. I have received a copy of this consent form to keep for myself and have read and understand all of it. Name or the research assistant explained anything I did not understand to me. Therefore, I agree to participate in the study.
|
______________________________________ Signature |
________________ Date |
|
______________________________________ |
|
|
Researcher’s Signature |