Wisconsin's Public Liberal Arts College

Informed Consent Template


Institutional Review Board

Informed Consent Template

 

(Sample Informed Consent)*

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:

Student Doe (contact information)

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:

IRB Chair
Telephone: (715) 394-8433
Email:  irb@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.

 


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