CONSENT TO PARTICIPATE IN RESEARCH
Title of Study: [Insert title of study.]
You are asked to participate in a research study conducted by [student name] under the supervision of Dr. XXXXX from the Department of Psychology, University of Windsor. If you have any questions or concerns about this research please feel free to contact [student name] at [email address] or Dr. XXXXX at [email and office phone]. The results from this study will form the basis of an honours thesis research project.
PURPOSE OF THE STUDY
[State what the study is designed to assess or establish.]
PROCEDURES
If you volunteer to participate in this study, we would ask you to do the following things:
[Describe the procedures chronologically using simple language, short sentences and short paragraphs. The use of subheadings helps to organize this section and increases readability. Medical and scientific terms should be defined and explained. Identify any procedures which are experimental.]
[Specify the participant’s assignment to study groups, length of time for participation in each procedure, the total length of time for participation, frequency of procedures, location of the procedures to be done, etc. Provide details about any plan to contact participants for follow-up sessions or subsequent related study.]
POTENTIAL RISKS AND DISCOMFORTS
[If your study involves any questions about current or past stress or traumatic experiences please include a statement that is similar to “Some people may experience some mild distress when answering questions about ………”. Remember that asking questions about health issues or other sensitive topics may be stressful for some people. If you are asking questions about past potentially stressful experiences please include a time frame – e.g. “Some people may experience some mild distress when answering questions about stressful dating experiences they may have had within the past year”]
[Describe any reasonably foreseeable risks, discomforts, inconveniences (including for example, physical, psychological, emotional, financial and social), and how these will be managed.]
POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY
[Describe benefits to participants expected from the research. If the participant will not benefit from participation, clearly state this fact.]
[State the potential benefits, if any, to science or society expected from the research.]
COMPENSATION
[State whether the participant will receive COMPENSATION – usually Participant Pool bonus points. Give the amount of points they will receive and state that they can be used towards eligible psychology courses.]
CONFIDENTIALITY
Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission.
[Please include a statement that the signed consent forms will be kept separate from the survey data and that only the researchers involved will have access to the data they provide. Also state that the data collected will be stored and kept secure by the faculty research supervisor and that if the data is not used for subsequent research or will not be published that the faculty supervisor will destroy the data at the end of the study. Also state that information from this study may be published at a later date but that only group information will be discussed.]
PARTICIPATION AND WITHDRAWAL
You can choose whether to be in this study or not. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. You may also refuse to answer any questions you don’t want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise which warrant doing so. [Indicate whether or not the participant has the option of removing the data from the study, and if so who they must contact to have their data removed.]
FEEDBACK OF THE RESULTS OF THIS STUDY TO THE SUBJECTS
[Include a statement of how research findings will be made available to participants and how/where/when they will be made available to participants.]
Web address: _________________________________________________
Date when results will be available: __________________________________
SUBSEQUENT USE OF DATA
[Please select one.]
These data will not be used in subsequent studies.
OR
These data will be used in subsequent studies.
Do you give consent for the subsequent use of the data from this study? 0 Yes 0 No
RIGHTS OF RESEARCH SUBJECTS
You may withdraw your consent at any time and discontinue participation without penalty. If you have questions regarding your rights as a research participant, contact:
Dr. Jill A. Singleton-Jackson
Chair, Psychology Departmental Research Ethics Committee
University of Windsor
Windsor, ON N9B 3P4
519-253-3000 ext. 4706
email: jjackson@uwindsor.ca
SIGNATURE OF RESEARCH SUBJECT/LEGAL REPRESENTATIVE
I understand the information provided for the study [insert title] as described herein. My questions have been answered to my satisfaction, and I agree to participate in this study. I have been given a copy of this form.
______________________________________
Name of Participant
______________________________________ ___________________
Signature of Subject Date
SIGNATURE OF INVESTIGATOR
These are the terms under which I will conduct research.
_____________________________________ ____________________
Signature of Investigator Date