Wisconsin's Public Liberal Arts College

Informed Consent Template


Institutional Review Board

Informed Consent Template

Subject Consent Form Sample #1 for Participation of Human Subjects In Research

Project Title: Social Influence in Group Decisions

Researcher: Jane A. Doe, Dept. of Psychology, 1234 CSH, UW-SUPERIOR,          (715) 394-xxxx     

Description: The purpose of this experiment is to examine the social interaction patterns that develop within the small groups. If you volunteer for this research study, you will be asked to participate in a series of group discussions and decisions. Groups will vary from 3 to 9 persons and the topics discussed will relate to issues of common concern to young adults and college students. All other subjects in the study will be fellow students completing the research requirement for their psychology course. The topics are neither embarrassing nor intended to be upsetting. You will first be asked to complete a questionnaire and then will discuss one to six of the topics related to items on the questionnaire with other group members. You may be asked to attempt to reach total agreement among group members on the topics. A second response will then be requested to each question discussed. The total time for your participation will be one hour.

The results of each individual's participation will be strictly confidential. The results of your participation will be recorded by group only. No names or individual identifying information will be maintained. With the exception of the researchers involved in running this study, nobody will be allowed to see or discuss any of the individual responses. Your responses will be combined with many others and reported in group form in a professional journal article.

The risks to you are minimal though you may encounter other individuals attempting to change your mind on some issues during the group discussions. Though all subjects will be asked to keep their comments constructive, theresearchers are trained to step in to protect individuals from hostile or inappropriate comments made during discussions. The discussions will be discontinued if any of the group members cannot refrain from inappropriate remarks to others.

The overall nature of the study will be explained as soon as you have completed your session. A summary report and explanation of the results will be made available to you when the study is completed if you so request.

Authorization: I have read the above and understand the nature of this study and agree to participate. I understand that by agreeing to participate in this study I have not waived any legal or human rights. I also understand that I have the right to refuse to participate and that my right to withdraw from participation at any time during the study will be respected with no coercion or prejudice.

If you have any concerns about your treatment as a subject in this study, please call or write:

Eleni Pinnow, IRB Chair
Telephone: (715) 394-8312
Email:  This link will open your email client for sending an email.epinnow@uwsuper.edu

This research project has been approved by the UW-Superior Institutional Review Board for the Protection of Human Subjects, protocol #_______

_________________________________ ________________

Subject signature                                             Date

*Subjects should be given a copy of this form for their records.

(Sample Informed Consent #2)*

1. Purpose:

The purpose of this experiment is to study how people remember lists of items. The results are intended to provide insights into memory processes.

2. Procedure:

You will be shown some lists of words one word at a time. After a given list has been presented, you will be asked to write down as many of those words as you can remember.

3. Time required:

Your participation will involve one session lasting approximately 45 minutes.

4. Risks:

It is not anticipated that this study will present any risk to you other than the inconvenience of the time taken to participate.

5.Your rights as a subject:

(i) The information gathered will be recorded in anonymous form. Data or summarized results will not be released in any way that could identify you.

(ii)If you want to withdraw from the study at any time, you may do so without penalty. The information collected from you up to that point would be destroyed if you so desire.

(iii) At the end of the session, you have the right to a complete explanation ("debriefing') of what this experiment was all about. if you have questions afterward, please ask your experimenter or contact:

Dr. John Doe (or faculty sponsor's name, for students)

Dept of Psychology, UW-SUPERIOR,          (715) 394- xxxx     

Also, once the study is completed, you may request a summary of the results.

6. If you have any concerns about your treatment as a subject in this study, please call or write:

Eleni Pinnow, IRB Chair
Telephone: (715) 394-8312
Email:  This link will open your email client for sending an email.epinnow@uwsuper.edu

This research project has been approved by the UW-Superior Institutional Review Board for the Protection of Human Subjects, protocol # _______

I have read the above information and willingly consent to participate in this experiment.

Signed: ___________________ Date: ______________

*Subjects should be given a copy of this form for their records.

Subject Consent Form Sample #3 for Participation of Human Subjects in Research

PLEASE DO NOT PUT YOUR NAME ANYWHERE ON THIS SURVEY. There is no need to identify yourself.

You are being asked to complete this survey to help researchers better understand some of the behaviors and attitudes of college students in the Midwest. Many of the questions ask about your plans and activities with respect to career and family. Thus, for some respondents these may be current activities and for others they may require either a look into the past or into the future. Please be as honest with us as possible and answer all questions to the best of your knowledge. You should be able to complete the questionnaire in about 25 minutes.

Once the study is completed, a summary of the results will be made available through the Sociology Department office.

Your participation in this survey is entirely voluntary. By completing this survey you are giving your consent to be involved in the research. If at any point you decide that you do not want to complete the questionnaire, please return it and inform the administrator. Your course grades will not be affected if youdecide not to participate.

Please feel free to ask any questions you may have of the person who is giving you this survey, especially if there is a word or phrase you do not understand. Feel free to write in the margins if you feel you need room to express or explain an answer.

Thank you for your cooperation and the time that you have put into the project.

If you should have concerns about your treatment as a subject in this study, please call or write:

Eleni Pinnow, IRB Chair
Telephone: (715) 394-8312
Email:  This link will open your email client for sending an email.epinnow@uwsuper.edu

 

This research project has been approved by the UW-Superior Institutional Review Board for the Protection of Human Subjects, protocol #______

Again, please do not put your name anywhere on this survey.

Thank you,

Dr. Jane Doe,          (715) 394-xxxx

*Appropriate for questionnaire/survey research, where data are recorded in an anonymous fashion, that does not address sensitive or illegal behaviors, and whose subjects are at least 18 years of age.

Subjects should be given this form for their records.


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