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 assess certain personal attitudes related to death and dying.  This research is part of Sarah Student's Senior Thesis research project at Dominican University of California, California.  This research project is being supervised by (Name of faculty research supervisor, title, department), Dominican University of California.

2. I understand that participation in this research will involve taking part in a one-hour phone interview, which will include a personal life history, as well as thoughts and feelings on the topic of death and dying.  

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 interviews will be recorded.  All personal references and identifying information will be eliminated when these recordings are transcribed, and all Participants will be identified by numerical code only; the master list for these codes will be kept by Sarah Student in a locked file, separate from the transcripts.  Coded transcripts will be seen only by the researcher and her faculty advisors. 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 May 1, 2010.

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 interview 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 interview.  If I experience any problems or serious distress due to my participation, Sarah Student will provide, at no cost to me, a one-time consultation with a licensed therapist.  Ms. Student may be contacted at (insert student's Dominican email address here).

8. I understand that if I have any further questions about the study, I may contact Ms. Student at [INSERT student’s Dominican email address] or her research supervisor, [INSERT Dominican faculty research supervisor’s name, phone and/or e-mail address], 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) 482-3547 and leaving a voicemail message, by FAX at (415) 257-0165 or by writing to the IRBPHP, Office of the Associate Vice President for 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.