Title of research study: [Insert title of research study here with protocol number, if applicable.]
Investigator: [Insert name of principal investigator]
[This template is provided as guidance only and recommended for use with research that involves collecting identifiable data through photography and/or audio or video recordings (when this data collection may be optional and not a condition of participation). This template must be adapted to your own project, and the list of specific permissions should be edited to your study.]
[Prior to submission to the IRB, all this guidance language must be removed. Only ‘clean’ final versions of consent documents will be accepted for review. If you have any questions on how to adapt a template to your study, please contact the HSPP for assistance.]
The purpose of this study is [state purpose of the study here] .
As part of this project, we will be [taking photographs, audio or video recordings] . Please initial in the spaces below for the uses of these [images and/ or recordings] that you consent to, and sign at the end of the release form. [Images and/ or recordings] will only be used in the ways you consent to. Your name will not be associated with these [images and/ or recordings] in any presentations or publications. Signing this release is voluntary.
[Images / Audio recordings / Video recordings] [reviewed/collected] by the research team may be used for:
1. _______ [Images / Audio recordings / Video recordings] can be used for project illustration.
2. _______ [Images] can be used for promotional materials, such as brochures or fliers.
3. _______ [Images / Audio recordings / Video recordings] can be used for classroom presentations.
4. _______ [Images / Audio recordings / Video recordings] can be used for academic conference presentations.
5. _______ [Images / Audio recordings / Video recordings] can be used for fundraising presentations/proposals.
6.________ [Images] can be used for newspaper or magazine publication
7. _______ [Images / Audio recordings / Video recordings] can be posted on a website for promotional purposes.
I consent to the use of my [image and/or voice] for the above-described purposes and certify that I am 18 years of age or older.
_______________________________________________
Signature
_______________________________________________
Printed Name
________________________
Date
Document Revision Date: August 13, 2014