Sample Consent Form

SAMPLE CONSENT FORM TO BE A RESEARCH PARTICIPANT

DOMINICAN UNIVERSITY OF CALIFORNIA

1. I understand that I am being asked to participate as a Participant in a research study designed to [INSERT RESEARCH TOPIC].  This research is part of [NAME OF RESEARCHER] research project at Dominican University of California, in San Rafael. This research project is being supervised by [NAME OF FACULTY RESEARCH SUPERVISOR, TITLE, DEPARTMENT]. 

2. I understand that participation in this research will involve taking part in [DATA COLLECTION METHOD, for example interview or survey], which will include a [WHAT ARE THE TYPES OF QUESTIONS THEY WILL BE ANSWERING, for example personal life history].  

3. I understand that my participation in this study is completely voluntary, and I am free to withdraw my participation at any time.

4. I have been made aware that the [DATE COLLECTION METHOD] will be recorded.  All personal references and identifying information will be eliminated before analysis, and all Participants will be identified by numerical code only; the master list for these codes will be kept in a locked file, separate from the raw data. Coded data will be seen only by the researcher and faculty advisor. One year after the completion of the research, all written and recorded materials will be destroyed.

5. I am aware that all study participants will be furnished with a written summary of the relevant findings and conclusions of this project. Such results will not be available until [INSERT DATE].

6. I understand that I will be discussing topics of a personal nature and that I may refuse to answer any question that causes me distress or seems an invasion of my privacy. I may elect to stop the [DATA COLLECTION METHOD] at any time.

7. I understand that my participation involves no physical risk, but may involve some psychological discomfort, given the nature of the topic being addressed in the research.  If I experience any problems or serious distress due to my participation, the researcher can be contacted at [INSERT CONTACT INFORMATION].

8. I understand that if I have any further questions about the study, I may contact the researcher or the supervisor, [INSERT FACULTY CONTACT INFORMATION], If I have further questions or comments about participation in this study, I may contact the Dominican University of California Institutional Review Board for the Protection of Human Participants (IRBPHP), which is concerned with the protection of volunteers in research projects. I may reach the IRBPHP Office by calling (415) 458-3759 and leaving a voicemail message, by FAX at (415) 257-0165 or by writing to the IRBPHP, Office of Academic Affairs, Dominican University of California, 50 Acacia Avenue, San Rafael, CA 94901.

9. All procedures related to this research project have been satisfactorily explained to me prior to my voluntary election to participate.

I HAVE READ AND UNDERSTAND ALL OF THE ABOVE EXPLANATION REGARDING THIS STUDY.  I VOLUNTARILY GIVE MY CONSENT TO PARTICIPATE. A COPY OF THIS FORM HAS BEEN GIVEN TO ME FOR MY FUTURE REFERENCE.

[IF COLLECTING ELECTRONICALLY, INDICATE THAT HERE]