INFORMED CONSENT TO PARTICIPATE IN (name of research project)

A research project on (topic) is being conducted by (name[s] of researcher[s]) in the Department of (department name) at Cal Poly, San Luis Obispo (or list other affiliation if the researcher[s] are not students or employees of Cal Poly). The purpose of the study is (a concise description of the objective[s] of the research).

You are being asked to take part in this study by (describe the activities/events/procedures involved in the subject's participation). Your participation will take approximately (indicate how much time the study is expected to take and the scheduling of sessions if the study takes place on more than one occasion). Please be aware that you are not required to participate in this research and you may discontinue your participation at any time without penalty (add "or loss of benefits", if applicable). You may also omit any items on the questionnaire(s) you prefer not to answer.

The possible risks associated with participation in this study include (state all reasonably anticipated minor or significant physical, psychological, social, or economic risks as described in Specific Ethical Criterion #1 in the Policy for the Use of Human Subjects in Research). If you should experience (indicate the possible negative outcomes of the research such as emotional distress), please be aware that you may contact (an appropriate referral source such as the campus Psychological Services, Health Center, or the researcher) at (note the phone number and location of the referral source[s]) for assistance.²

Your responses will be provided anonymously to protect your privacy. Potential benefits associated with the study include(describe any anticipated benefits to the individual participants as well as any benefits to others and/or to the understanding of an area of investigation).

If you have questions regarding this study or would like to be informed of the results when the study is completed, please feel free to contact (name of the researcher[s] and/or the student researcher's faculty advisor) at (phone number of the researcher or, in the case of a student researcher, the office phone number of the student's faculty advisor). If you have questions or concerns regarding the manner in which the study is conducted, you may contact Dr. Steve Davis, Chair of the Cal Poly Human Subjects Committee, at 756-2754, sdavis@calpoly.edu, or Dr. Susan Opava, Dean of Research and Graduate Programs, at 756-1508, sopava@calpoly.edu.

If you agree to voluntarily participate in this research project as described, please indicate your agreement by completing and returning the attached questionnaire. Please retain this consent cover form for your reference.

¹This serves as an example only; other formats or wordings may be appropriate, provided they include the necessary informed consent content listed in the Guidelines for Human Subjects Research Protocol and discussed in the Policy for the Use of Human Subjects in Research. Regardless of the format, keep in mind that the consent information must be presented in language that can reasonably be expected to be clear and understandable to the prospective subjects or the prospective subjects' legally authorized representatives.

²If your study involves greater than minimal risk, you should include more detailed information about possible recourse if harm is experienced due to participation in the study. For clarification of minimal risk, see the Policy for the Use of Human Subjects in Research.

Go back to the Human Subjects Table of Contents.