Subject Informed Consent Formpage 1 of 2

Instructions

This form is used in research involving human subjects. Each participant interviewed as part of the research must provide their consent prior to participating in the research.

Please provide the participant with a brief description of the nature and purpose of the research and the anticipated products, the researcher’s name, address, phone number, and related information.

  1. Print a copy of this form for each participant.
    Note the content of this form can be adjusted to better reflect the research as necessary (a word format version is provided for this purpose).
  2. Complete all the information on the form.
  3. For every subject, have both the subject and the project researcher sign the form.
  4. Send the completed forms (all together, once interviews are over) to the Chair of the TSE Ethics Committee, Professor David Holdsworth:

Address:
David Holdsworth
Chair, TSE Ethics Committee
Environmental and Resource Studies Program, Trent University
1600 West Bank Dr. Peterborough, ON K9L 0G2 / Mailbox Location (for hand delivery):
ESC C202 (TSE office)
FAX:705-748-1205
Email:

Research Involving Human Subjects within Trent School of the Environment

1.Research Title:

2.Person Giving Consent

A.Name:
B.Telephone Number (or other contact):

3.Researcher

A.Name:
B.Telephone Number:
C. Address:
4.Date of Research Activity (mm/dd/yyyy):

5.Faculty Supervisor

A.Name:
B.Telephone Number:

6.Placement Organization Supervisor

A.Name:
B.Telephone Number:

I, the undersigned, voluntarily agree that the researcher may use the information and quotations from our interaction, and afterwards store them, subject to the following conditions:

No conditions

That my anonymity be guaranteed

That I be given an opportunity to see and comment on a rough draft of the research product, before the final copy is submitted

Other conditions (please specify):

Form of interaction between the researcher and the person giving consent (e.g., taped interview, questionnaire, focus group, etc.):

Signature of Person Giving Consent / Date (mm/dd/yyyy)
Researcher’s Signature / Date (mm/dd/yyyy)