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
*** Be sure to see “Other considerations” below.
Anyone signing a Consent Form should be given a copy of their signed 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. 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: Signed consent forms will be stored in a locked file cabinet in _____________ (list location of locked storage) accessible only to ____________, separate from electronic data/surveys/questionnaires/audio/video recordings and transcripts (material can not be stored in an undergraduate's residence). Electronic data will be stored on a password-protected computer, accessible only to _______________. The information you provide will be kept confidential by assigning a code number to the data. The audio/video recordings will be erased/deleted on ___________ after the study is completed (if applicable).
Participation in this study should take approximately _______ minutes for the (questionnaires/interviews/surveys/focus groups) 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.
If you have questions or concerns about this study, you may contact ____________ at ___________ (telephone number) or _____________ (email address). By signing below, you verify that you have read this consent form and agree to participate in this ____________ (questionnaire/focus group/interview/survey) and that you have received a copy of this consent form.
____________________________ (Signature) _________________ (Date)
____________________________ (Printed name)
* This study has been approved by the Clark Committee for the Rights of Human Participants in Research and Training Programs (IRB). Any questions about human rights issues should be directed to the IRB Chair, Dr. James P. Elliott (508) 793-7152.
- 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 recording is used, the Consent Form or Statement of Rights must state “I give permission” or “I understand that video/ audio recording will be used” and have a separate signature line.
- 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.