Fillable Printable Informed Consent Form (sample) - Illinois

Informed Consent Form (sample) - Illinois

Informed Consent Form (sample)

Illinois State University

Department of Psychology (2012)

Informed Consent for Participants

Study Name:

Principal Investigator:

Faculty Supervisor:

_________________

PLEASE READ THIS DOCUMENT CAREFULLY. YOUR SIGNATURE IS REQUIRED FOR

PARTICIPATION. YOU MUST BE AT LEAST 18 YEARS OF AGE TO GIVE YOUR CONSENT TO

PARTICIPATE IN RESEARCH. IF YOU DESIRE A COPY OF THIS CONSENT FORM, YOU MAY

REQUEST ONE AND WE WILL PROVIDE IT.

The policy of the Department of Psychology is that all research participation in the Department is

voluntary, and you have the right to withdraw at any time, without prejudice, should you object to

the nature of the research. You are entitled to ask questions and to receive an explanation after

your participation.

Description of the Study:

This is a ____ session study in which a number of different kinds of psychological tests and

measures are being evaluated. To do this, we will ask you to do the following: (include a brief

description of the kinds of activities, e.g. "measures of attitudes, feelings, knowledge and skills.")

Nature of Participation:

You will participate in ____ sessions. In the (first) session you will: (describe second session, if

applicable)

Purpose of the Study:

To evaluate several psychological tests and measures, and the possible relations between them.

This means we want to find out some general information about the usefulness of (your variable

inserted here) and how people react and behave. We are only interested in an evaluation of these

variables, and how they are related to one another. We are NOT interested in any specific

individual.

Possible Risks: (e.g., for a questionnaire study...)

a) When (filling out questionnaires,) you may (come across a question or answer choice) that you

find unpleasant, upsetting, or otherwise objectionable. For instance, (a few of the questions may

cause you to think about negative emotional states.)

b) You may feel that you have performed poorly on a test. For many of the activities, tests and

questionnaires we are evaluating, there is no right or wrong answers. However, for some activities,

it is to be expected that some people will do better than others on some of the tests. We

encourage you to discuss this with the test administrator during the debriefing period, when all

procedures have finished.

c) You will be asked to provide confidential information about yourself.

Possible Benefits:

a) When your participation is complete, you will be given an opportunity to learn about this

research, which may be useful to you in your course or in understanding yourself and others.

b) You will have an opportunity to contribute to psychological science by participating in this

research.

Compensation for your Time:

You will receive credit or extra credit in a psychology course. You will receive extra credit simply by

virtue of coming to your appointment; you are free to withdraw your participation at any time

without penalty. Alternative means of earning extra credit are available. Please consult your

instructor or class syllabus for information regarding alternative means of earning credit or extra

credit in your course.

Confidentiality:

You will be assigned a code number which will protect your identity. All data will be kept in secured

files, in accord with the standards of the University, Federal regulations, and the American

Psychological Association. All identifying information will be removed from questionnaires as soon

as your participation is complete. No one will be able to know which are your questionnaire

responses. Finally, remember that it is no individual person's responses that interest us; we are

studying the usefulness of the tests in question for people in general.

Opportunities to Question:

Any technical questions about this research may be directed to:

Principal Investigator: ________________________

Phone: ________

Any questions regarding your rights as a research participant or research-related injuries may be

directed to ISU's Office of Research, Ethics, and Compliance, 438-2520.

Opportunities to Withdraw at will:

If you decide now or at any point to withdraw this consent or stop participating, you are free to do

so at no penalty to yourself. You are free to skip specific questions and continue participating at no

penalty.

Opportunities to be Informed of Results:

In all likelihood, the results will be fully available around ______________ (date). Preliminary

results will be available earlier. If you wish to be told the results of this research, please contact:

Principal Investigator: ________________________

Phone: ________

He/she will either meet with you or direct you to where you can read a copy of the results. In

addition, there is a chance that the results from this study will be published in a scientific

psychology journal, which would be available in many libraries. In such an article, participants

would be identified in general terms as undergraduate students at a large state university.

Your signature below indicates that you voluntarily agree to participate in this study.

Dated this ______________ day of (month) _____________, 20 __

__________________________

Signature of Participant

Signature of Person Obtaining Consent