Division of Psychiatry & Applied Psychology
School of Medicine, Faculty of Medicine & Health Sciences
Project Title: …………………………………………………………………………………
Researcher: [Name]…………………………. [university e-mail] ..……………………………..…
Supervisor [Name] ………………..…….. [university e-mail] ……………………………….…
Ethics Reference Number: …. [to be inserted following ethical review]
 Have you read and understood the Participant Information? YES/NO
 I agree to [ insert “answer a questionnaire”, and/or “take part in an interview that will be recorded” and/or, etc. Provide a yes/no choice for each option] YES/NO
 Do you know how to contact the researcher if you have questions about this study? YES/NO
 Do you understand that you are free to withdraw from the study without giving a reason? YES/NO
 [Insert for anonymous questionnaire studies only] Do you understand that for anonymous questionnaire studies, once you have completed the study and submitted your questionnaire, the data cannot be withdrawn? YES/NO
 [Insert for interview studies only] Do you understand that once you have been interviewed it may not be technically possible to withdraw your data unless requested within a certain timeframe ? YES/NO
 Do you give permission for your data from this study to be shared with other researchers in the future provided that your anonymity is protected? YES/NO
 Do you understand that non-identifiable data from this study might
be used in academic research reports or publications? YES/NO
Signature of the Participant ………………………………………. Date: …….
Name (in block capitals) ……………………………………….…..
[insert for paper-based questionnaires only] This consent form will be detached from the completed questionnaire and stored separately. Your answers will not be identifiable.
OR
[insert for internet studies] “By clicking the button above/below I indicate that I understand what the study involves and that my answers are anonymous. I agree to take part and I understand that once I click ’submit’ at the end of the questionnaire it will not be possible to withdraw the data.”
[Insert version number in the footer: Every time you make changes to the participant consent form you will need to update the version number] 1