Fillable Printable Research Consent Form Sample - Tufts University
Fillable Printable Research Consent Form Sample - Tufts University
Research Consent Form Sample - Tufts University
Tufts University Institute for Global Leadership
96 Packard Avenue
Medford, MA 02155
USA
CONSENT FORM EXAMPLE # 3
STUDY DETAILS:
•
CONSENT TYPE: ORAL CONSENT WITH SHORT FORM WRITTEN
CONSENT
•
PARTICIPANTS: OVER 18
EXAMPLE ONLY – DO NOT COPY VERBATIM
CONSENT FORMS MUST BE APPLICABLE TO YOUR PARTICULAR
RESEARCH QUESTION AND METHODOLOGY
Oral Consent (to be used in conjunction with short form written consent)
STUDY TITLE: Rural Education in Balan, Haiti
INVESTIGATOR: Valerie Schenkman
BACKGROUND AND PURPOSE: You are being asked to take part in a research project,
which is being organized by RESPE (Research and Engagement Supporting Poverty
Elimination), a group of Tufts University students supported by the Tufts Institute for Global
Leadership. The purpose of this research project is to learn more about the state of Balan’s
education system, its effects on the community as a whole, and in turn what factors in the
community affect its education. My research is contributing to a greater assessment of
where, how, and with whom, Tufts University can mobilize its academic resources in the
possibility of supporting Haitian-led initiatives working to eliminate poverty and its effects in
the community. As a community member of Balan, you are in a position to provide me with
insight into the situation, and I would appreciate it if we could interview you.
PROCEDURES: The format of the interview will be a discussion or perhaps a group
discussion. I expect that the interview will take no longer than 1 hour. With your permission, I
will audiotape the interview solely for the purposes of accurately transcribing the
conversation. With your permission I would also like to take photographs. The audiotapes
and photographs, as well as the transcriptions will be stored securely at the Institute for
Global Leadership in the USA. The photographs will be used to present our research at
various conferences and at Tufts University.
CONFIDENTIALITY AND RISK: There is some risk involved if, for example, you divulge
confidential information. Therefore, if you wish pseudonyms to be used to protect your
privacy and confidentiality, I will be happy to do so. Alternately, if you wish to be quoted by
name on anything in particular I am also happy to accommodate this request. Please know
though that you do not have to answer any questions or discuss any topics that make you
feel uncomfortable.
Tufts University Institute for Global Leadership
96 Packard Avenue
Medford, MA 02155
USA
WITHDRAWAL OF PARTICIPATION: Should you decide at any time during the
interview
or
discussion that you no longer wish to participate, you may withdraw your consent without
prejudice.
COSTS BENEFITS TO YOU: There are no direct costs involved with participation,
although you may miss an hour of work and possibly pay for that time. There are also no
direct benefits to you. However, your participation will contribute to a greater awareness of
Haiti and greater awareness of its successes and challenges as you and your community
view them, as well as the opportunity to bring those challenges home to Tufts University
and make an effort to address them. My final report will be presented at various
conferences and your participation will help to bring greater attention to the issues facing
Balan and greater Haiti.
REQUEST FOR MORE INFORMATION: You may ask more questions about the study at
any time. Please contact Valerie Schenkman at
while I am in Haiti. You may also contact Sherman
Teichman at the Institute for Global Leadership in the US by calling + 1(617) 627-3415. This
study has been approved by the Institutional Review Board at Tufts University, so you may
contact the IRB Administrator, Lara Sloboda, by calling + 1(617) 627-3417.
SIGNATURE: I confirm that the purpose of the research, the study procedures, the possible
risks and discomforts as well as benefits have been explained to the participant.
All
questions
have been answered. The participant has agreed to participate in the study.
Signature of Person Obtaining Consent Date
The
participant
agrees
to
be
audio-taped
YES
NO
Initial
The
participant
agrees
to
be
photographed
YES
NO
Initial
The
participant
agrees
to
be
videotaped
YES
NO
Initial
The
participant
would
like
his/her
name
to
be
used
YES
NO
Initial
Witness Signature Date
Witness Name Printed
valerie.schenkman@tufts.edu or at
Tufts University Institute for Global Leadership
96 Packard Avenue
Medford, MA 02155
USA
CONSENT TO PARTICIPATE IN RESEARCH STUDY
Short Form WrittenConsent (to be used with oral consent form)
STUDY TITLE: Rural Education in Balan, Haiti
INVESTIGATOR: Valerie Schenkman
Short-Form Written Consent
I confirm that the researcher has explained the elements of informed consent to the
participant.
The subject knows that their participation is voluntary, and that they do not need to
answer all questions. The purpose of the research as well as the risks and benefits
have been explained. The procedures as well as the time commitment have been
outlined. The participant understands issues of confidentiality.
Witness Name
Witness Signature
Participant Name
Participant Signature
