Sample Informed Consent Form for Internet Surveys

Mills College Human Subjects Protocol

Sample Informed Consent Form for Internet Surveys

Dear Research Participant,

Please read this screen carefully. It provides important information about a research project being conducted by [insert your name and affiliation here; if you are a student, identify the name of your academic program] that received IRB approval by the Mills Committee for the Protection of Human Subjects on (date). Your participation is completely voluntary and you can withdraw at any time by closing this link. [If you are sending your study to participants via email, indicate where you got their contact information. Example:You likely received information about participating in this study through a listserv, email to a community group, or flyer.] If you have any questions about the study, contact information is provided below.

The purpose of this study is to [brief description of the goals of the research]. You must be [age or qualifications] to participate in this study. The questionnaire asks you about [summarize the nature of the questionnaire. Address any aspects of the questionnaire that the participant might find uncomfortable].

Participation entails completing this web-based survey that takes approximate [X] minutes to complete. [The exact nature of any commitments made ty the researcher, such as the amount of money to be paid to individuals for participation, should be specified here. Example:All participants who complete the questionnaire will be entered into a drawing for a $20 Amazon or Target gift e-card, awarded to 1 of every 20 participants.]

PARTICIPATION GUIDELINES

You may withdraw our consent and discontinue participation at any time. There is no penalty for withdrawal [add the following clause if your study provides reimbursement of money or gift: with the exception that you will not be eligible for the study gift]. Your answers will be kept confidential. Your answers will be kept confidential. Your responses are anonymous. The results of this study will describe group responses only, not the responses of individuals. Your completion and submission of the study survey indicates your consent to participate in the study. If you wish to receive a copy of the general results of this study, please indicate this by providing contact information at the end of the survey. Study results will be forwarded to you when the study is completed. No individual results are provided.

POTENTIAL BENEFITS OF THE STUDY

[Briefly describe potential benefits of study participation here.]

RESEARCHER CONTACT INFORMATION

If you have any questions or concerns about this research, please contact [your name] at this address:

[Provide address and email contact. Students should not use their personal contact information. Write in your name c/o the name and address of your research supervisor. Provide your research supervisor’s office phone number. Students should not use their personal email for research purposes. This policy is for students’ personal protection. We encourage students to create an email address specifically for their study (e.g., gmail). ]

WHAT TO DO NEXT

Read the informed consent below to begin. [If you use Survey Monkey add: This link does not permit you to save your answers and return to the survey later. Please allow enough time to complete the survey in one sitting.]

~INFORMED CONSENT~

“By clicking ‘next,’ I verify that I am 18 years or older and hereby give my consent to participate in [name of study]. I understand that my participation is confidential and anonymous. I understand that I may withdraw from the study at any time [if needed: but that not completing the entire survey makes me ineligible for the [gift].] I understand that I may request the general results of this study and that I will not receive information about my individual answers.I understand that I can participate only one time in this study.”