SAMPLE INFORMED CONSENT
Dear______:
My name is ______and (your title) ______at Morehead State University in the Department of ______. I am requesting your assistance with a research project I am conducting on ______. Let me emphasize that you do not have to participate. If you do not wish to take part in the survey, you do not have to answer any of the questions. Completing this survey is voluntary and you may withdraw from the study at any time.
You must be 18 years of age or older to participate. (Researcher must verify that students are 18 years of age or older.) This study has been reviewed to determine that participants’ rights are safeguarded and there appears to be minimal risk or discomfort associated with the completion of the survey. You may choose to discontinue your participation at any time. You may also skip any questions you do not wish to answer. Also, you need to understand that participating or not participating in the survey has no impact on your grade in this or any other class. Your decision to volunteer to complete the survey cannot hurt or help your grade. If extra credit is offered to those participating in the study and you do not wish to participate or are under the age of 18, an alternative method of extra credit will be offered.
The answers you provide will be kept strictly confidential and all research subject responses (completed survey, audio tapes, and video tapes) will be stored in a ______, accessible only to the researcher. (Researcher must insert the secure location.) Please feel free to ask for help if something does not make sense to you or if you have any questions. If you experience any discomfort, you may contact (Researcher must insert referral agencies and telephone numbers).
If you decide to volunteer, please be sure to print your name on the form and sign it to indicate your willingness to participate. That will be our indication that you understand the purpose of the survey and that you are willing to help.
NAME (please print):______
Signature:______
If you have any questions or concerns, you may contact the researcher: (Researcher must provide contact information including office location, telephone number, and email address).