Appendix A

Informed Consent Form - Sample

I, ( name of participant ), have read the attached letter describing a study to be conducted under the auspices of Bates College, Lewiston, Maine, Department of                             , to be conducted by ( name of researcher ).

I hereby consent to participation in this study.

I understand that I am free to discontinue my participation at any time without suffering any disadvantage.

I also understand that the findings of the study will be interpreted and recorded only on a group basis with no identification of specific individuals. All information about individuals will be held in confidence, to the extent permitted by law.

I understand that some aspects of the study’s purpose may be withheld from me until its end. However, I also understand that at that time, I have a right to a complete explanation of the nature and purpose of the study. If I have any questions or wish further information about the study, I understand that I may call ( name of researcher ) at ( telephone number ). I further understand that if I have additional questions that may not be answered by the researcher, I may call his/her advisor, ___________ at ( telephone number ), or the chair of the Department of __________.

In addition to consent to participation, my signature confirms that I have received a copy of this consent form together with any attachments which describe the research to be conducted.

 

Dated__________

____________________________________ Signature of research participant