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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, providing details of any physiological or
experimentalproceduress if applicable). 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
research2 and you may discontinue your participation at any
time without penalty (add "or loss of benefits", if applicable).
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
or strained muscles), 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.3,4
Your confidentiality will be protected (describe the manner in which
confidentiality will be safeguarded, including an instruction for
participants to not write their names on written materials, if
applicable).5 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 signing below (or, in cases
in which a signature is not needed6 you may
substitute "by completing the attached questionnaire". Please
keep one copy of this form for your reference, and thank you for your
participation in this research.
_____________________________________________ _______________________
Signature of Volunteer7 Date
_____________________________________________ _______________________
Signature of Researcher Date
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 the study involves completion of self-report measures such as questionnaires and surveys, add the phrase, "you may omit any items you prefer not to answer."
3If 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.
4If the study involves testing a treatment of a physical or mental health problem, the subjects should also be informed of any alternative treatments (other than that which they may receive in the study) that could benefit them in treating this problem.
5If a questionnaire or survey will be anonymous (i.e., there will be no method by which even the researcher[s] may determine the data associated with specific individuals) rather than confidential, substitute a sentence such as, "Your responses will be provided anonymously to protect your privacy."
6For clarification of such instances, see the Guidelines for Human Subjects Research Protocol and the Policy for the Use of Human Subjects in Research.
7In the event that volunteer subject is a minor (<18 years of age in the State of California), or is otherwise unable to give consent for their participation, the signature should be that of the parent or guardian. In addition, the minor subject's informed consent must also be obtained.