Sample consent form

The sample provided below is intended as a guide to assist you in providing full information and obtaining and documenting participants’ informed consent. Feel free to draw from it liberally or use as a “boilerplate”. See item 4 of the HSC approval checklist (in appendix C on web site) for a listing of issues that should be addressed in your consent form. See also the Documentation of Informed Consent Checklist (Appendix A) on the website for further information.]

Sample Consent Form

CENTRAL CONNECTICUT STATE UNIVERSITY

Department of [ ]

1615 Stanley Street

New Britain, CT 06050

Phone number(s)

e-mail address(es)

PROJECT TITLE HERE

List Principal Investigator’s name and position

List other investigators and/or faculty supervisor or sponsor

INFORMED CONSENT STATEMENT

1. Invitation to Participate and Description of the Project. You are being asked to participate in our study of [ ]. We are investigating this topic in order to further our understanding of [ ]. [Describe how participant was recruited to participate if it is not obvious]. Your participation in the research study is voluntary. Before agreeing to be part of this study, please read and/or listen to the following information carefully. Feel free to ask questions if you do not understand something.

2. Description of Procedure. If you participate in this study, you will (may) be asked to [list and describe all procedures here; include information on the duration of involvement].

3. Risks and Inconveniences. [List all risks here. List protections from risk here. Risks are not limited to the physical. They may also involve the potential for psychological or social injury, fatigue or other. For example, consider embarrassment or other feelings that are uncomfortable. For some studies a statement like the following might be useful: There is a possibility that some of the questions in the interviews may make you feel uncomfortable. We will be asking you about personal things and you may feel embarrassed at times when taking about [ ]. This rarely happens, but if you do feel uncomfortable, you can do any of the following: you can choose not to answer certain questions, you can take a break and continue later, you can choose to stop the research (interview, etc). If you wish you can call [ ] or someone else of your choosing to talk about your feelings. Please note that some of these issues may not be applicable to your study and you may have other protections from risk in place. Please describe such here.]

4. Benefits. [Describe all benefits here. Even if your study has no direct benefits to the participant you should describe the general class of benefits to accrue, such as: This study was not designed to benefit you directly, however, there is some possibility that you may learn about [ ] through your participation. In addition, what we learn from the study may help us to better understand [ ].

5. Financial (or other) considerations: [Describe any financial or other (e.g., course credit) considerations.]

6. Confidentiality. [Describe confidentiality arrangements. For example, if applicable you may state: Any and all information obtained from you during the study will be confidential. Your privacy will be protected at all times. You will not be identified individually in any way as a result of your participation in this research. The data collected however, may be used as part of publications and papers related to [the research topic]. If participation is anonymous you may note that here.]

7. Voluntary Participation. Your participation in this study is entirely voluntary. You may refuse to participate in this research. Such refusal will not have any negative consequences for you. If you begin to participate in the research, you may at any time, for any reason, discontinue your participation without any negative consequences.

8. Other considerations and questions. Please feel free to ask any questions about anything that seems unclear to you and to consider this research and consent form carefully before you sign.

Authorization: I have read or listened to the above information and I have decided that I will participate in the project described above. The researcher has explained the study to me and answered my questions. I know what will be asked of me. I understand that the purpose of the study is [ ]. If I don't participate, there will be no penalty or loss of rights. I can stop participating at any time, even after I have started.

I agree to participate in the study. My signature below also indicates that I have received a copy of this consent form.

Participant’s signature____________________________________

Name (please print)______________________________________

Date________

[If applicable, Signature of Person Obtaining Consent]

[Please be reminded that signed, fully informed permission of parent(s) or guardian (s) as well as the assent of participants will be required for studies involving minors.]

If you have further questions about this research project, please contact the principal investigator, [name, at (860) 832-xxxx, e-mail: ] or faculty supervisor [if different, name, at (860) 832-yyyy, e-mail: ]. If you have questions about your rights as a research participant or if you have a research related complaint please contact Ms. Mimi Kaplan, Assistant Director, Office of Sponsored Programs and CCSU Human Studies Council Administrator at (860) 832-2366, e-mail: Kaplan@ccsu.edu; or Dr. Bradley Waite, Chair, CCSU Human Studies Council at (860) 832-3115, e-mail Waite@ccsu.edu.

The participant will be given one copy of this consent form. One copy of this form is to be kept by the investigator for at least five years.

[version 8.30.01]