INFORMED CONSENT FORM
(______study title______)
You are being asked to participate in a study entitled______[study title]______, conducted by ______.
The following points may be of interest to you as a participant in this study:
1)The purpose of this study is to ______. You will be asked ______, and will also be asked to ______.
2)Please keep in mind that we are interested in your experiences and impressions – there are absolutely no right or wrong answers to any of the questions we ask. More importantly, keep in mind that it is the ____object under investigation______ that are under investigation, and any differences in how you view the ___objects___ or in task performance will be evaluated with respect to the ___objects .
3)By signing this consent form and participating in the study, you are giving consent to use the data collected in any future publications. As a participant, your anonymity will be protected. The information obtained will be reported in a collective manner and no individually identifiable material will be published.
4)This study will be audio taped and portions of it will be videotaped for later analysis. In addition, it may be helpful (for illustration or clarification of study findings) to publish non-identifying photo or video record. You will be given the option of whether or not you wish to give your consent to the use of the recordings from your session in this way; refusal will not in any way affect your eligibility to participate in the study. Video and audio tapes will be destroyed one year after the completion of the study.
5)There are no known discomforts or stresses associated with the study. There are also no foreseeable risks or dangers associated with the study.
6)If you have any questions you may contact ___name___ at ___phone number___ or ___name___ at ___phone number____.
7)The Institutional Review Board oversees research at MercerUniversity that involves human participants. Questions or problems regarding your rights as a participant should be addressed to the Chair of the Institutional Review Board, Mercer University, 1400 Coleman Avenue, Macon, GA, 31207; Telephone (478) 301-4101.
8)Participants will not receive financial compensation for participation in this study.
9)Financial compensation for such things as disability or discomfort due to injury is not available. Unless found to be liable in a court of law for medical damages, no other compensation for damages is available from MercerUniversity or study investigators.
10)You are making a decision whether to participate or not to participate. Your signature indicates that you have decided to participate having read the information provided above. You will be given a copy of this form for your record.
11)Participation is entirely voluntary and can be withdrawn at any time without penalty. If you elect to withdraw your consent to participate, all data and recordings of your session will be destroyed.
I have read and understand the conditions listed above and agree to participate in this ______study name ______.
______
Signature of Participant DatePrinted Name of Participant
I do do not
agree to allow non-identifying photo or video images of my sessions to be used as needed in publications arising from this study.
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Signature of Participant DatePrinted Name of Participant
___name____
______
Signature of InvestigatorDatePrinted Name of Investigator
___name____
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Signature of InvestigatorDatePrinted Name of Investigator