C. Additional Sample Consent Form for Student Researchers
Title of Study in Lay Language
REQUIREMENTS:
Identify yourself by name,
affiliation, and your
student status. Mention the
name of the faculty supervisor.
Also indicate for whom consent
is being given, e.g., is consent
being given by the actual participant,
the parent of a minor who will
be participating, etc. Clearly state that
participating in the study is voluntary.
SAMPLE WORDING:
I authorize Jane Doe, M.A., a doctoral
student under the supervision of Dr. ____ in
clinical psychology at Pepperdine University,
[name of school],
to include me (my child, etc.)
in the research project entitled “.....”. I
understand my participation in this study is
is strictly voluntary.
State the purpose of the
research project in lay language
and how long the study will last.
I have been asked to participate in a research
project which is designed to study ...... The
study will require ... meetings of approximately
... hours each.
State why the participant has been
asked to participate.
I have been asked to participate in this study
because ...... (e.g., I am a student, I experience
panic attacks, my child is experiencing
difficulties in school, etc.)
In lay language, state the
procedures, that is, what
will the participant be asked
to do. Be as specific as
possible.
I will be asked to ...... (e.g., complete
intelligence testing, complete paper-pencil
tests that will provide information about how I
feel about myself, etc.)
If audio or videotaping will
be used in the study, this
needs to be noted in the
consent form along with the
usages of the recorded
material and how the material
will be handled upon the
completion of the study.
I understand that I will be audiotaped
(videotaped) if I decide to participate in this
study. The tapes will be used for research
purposes only. The tapes will be stored
in a locked file cabinet and will be destroyed
..... (state when tapes will be destroyed).
State the potential risks,
regardless of how minor (e.g.,
fatigue, boredom, etc.),
involved by participating in
this study. Also describe
the precautions that will be
taken if participants
experience discomfort.
The potential risks of participating in this
study are ..... In the event you do experience
..... (e.g., fatigue, etc.), ..... (e.g., a break will
be provided, etc.).
REQUIREMENTS:
SAMPLE WORDING:
Depending on the population and the
nature of the study, the IRB may
recommend that a list of referral sources
be made available for use by the participant.
With some populations and studies, it may
be a good idea to have the list accompany
the consent form, although on a separate
page. This list must include low fee service
providers.
State the potential benefits
to the participant. If none,
so state.
I understand there is no direct benefit from
participation in this study, however, the
benefit(s) to the profession (or humanity)
may include......
or
I understand the possible benefits from my
participation in this study include .......
If a treatment is used in the
study, identify the alternative
treatments that exist and
explain why the alternatives
are not being used.
I understand that treatments other than the
one(s) used in this study are available, such as
...... The reason these other treatments are not
being used is ......
Clearly state that participants
are free to withdraw from the
study at any time without penalty.
Furthermore, the participant has
the right to refuse to answer
any question. Also state the
investigator has the right to
terminate the participant's
study participation without
regard for the participant's
consent.
I understand that I have the right to refuse to
participate in, or to withdraw from, the study at
any time without prejudice to ..... ( e.g., my
current or future medical care, etc.). I also
have the right to refuse to answer any question
I choose not to answer. I also understand that
there might be times that the investigator may
find it necessary to end my study participation.
Discuss the confidential
treatment of data and how the
data will be stored.
I understand that no information gathered
from my study participation will be released to
others without my permission, unless such
a disclosure is required by law. I understand that under
California law, the privilege of confidentiality does not
extend to information about the abuse of a child. If the
investigator has or is given such information, she (or he)
is to report it to the authorities. The obligation to report
includes alleged or probable abuse as well as known
abuse.
REQUIREMENTS:
SAMPLE WORDING:
Furthermore, under California law, the investigator is
obligated to report any evidence of physical abuse
against elders or dependent adults, or if a person
indicates she or he wishes to do serious harm to self,
others, or property.
(Preferred if
children/adolescents are participants)
or
I understand that no information gathered from
my study participation will be released to others without
my permission, or as required by law.
Under California law, an exception to the
privilege of confidentiality includes but is not
limited to the alleged or probable
abuse of a child, physical abuse of an
elder or a dependent adult, or if a person
indicates she or he wishes to do serious harm
to self, others, or property.
The data being referred to are the raw
data (e.g., questionnaires, tapes), not
the database used for analysis.
If participants are paid or provided
some sort of incentive, specify
the dollar amount if reimbursed
in cash and terms of reimbursement.
If not paid or provided an incentive,
also indicate.
If the findings of the study are published or
presented to a professional audience, no
personally identifying information will be
released. The data gathered will be stored in
locked file cabinets to which only the investigator
(or research team members) will have access.
(or The information gathered will be made
available to other investigators with whom the
investigator collaborates in future research.
If such collaboration occurs, the data will be
released without any personally identifying
information so that I cannot be identified, and
the use of the data will be supervised by the
investigator.) The data will be maintained in a
secure manner for 3 years (or 6 yrs. for studies
that fall under HIPAA) at which time the
data will be destroyed. (or The data may be
kept for an indefinite period of time [or a minimum of 3
(6) years] for research purposes. After the completion
of the study, the data will be destroyed.)
I understand that I will receive $... for my study
participation. If I choose to withdraw from the
study, or I must end my study participation
through no fault of mine, I will receive the full
amount of reimbursement.
Or
REQUIREMENTS:
SAMPLE WORDING:
I understand that I will receive $... for my study
participation. If I choose to withdraw from the
study, I will be reimbursed $... for each hour
of study participation I have completed. If the
investigator chooses to end my study
participation, I will receive the full amount of
reimbursement.
OR
I understand I will receive no compensation,
financial or otherwise, for participating in study.
Identify the person responsible
for the study procedures and
where the person can be reached
to answer questions. Also
identify the person designated
by the investigator's institutional
I understand that if I have any questions
regarding the study procedures, I can contact
..... (identify yourself) at ..... (address and
phone number) to get answers to my
questions. If I have further questions, I may
contact Dr. _________________,(name of faculty
supervisor and contact information). If I have further
questions about my rights as a research participant, I
may contact
Dr. _________________, Chairperson of the
(Seaver or GPS) Institutional Review Board,
Pepperdine University, (insert contact information for
Seaver or GPS IRB as appropriate).
affiliation as responsible for
the use of human participants.
Include this statement at the end
of the consent form.
Provide signature and date
lines for the participant.
I understand to my satisfaction the information
in the consent form regarding my
participation in the research project. All of my
questions have been answered to my satisfaction. I have
received a copy of this informed consent form which I
have read and understand. I hereby consent to
participate in the research described above.
___________________________________
Participant's signature
___________
Date
If the participant is a
minor or unable to legally sign
for other reasons, obtain the
consent of the parent(s) or
legal guardian/custodian. If both
parents with legal custody are
The participant is a minor (age _____), or is
unable to sign because ________________
____________________________________
____________________________________
REQUIREMENTS:
SAMPLE WORDING:
required to consent to a minor’s
participation, an additional signature
line can be added. For minors 7-17
years, an assent form should be
prepared. The assent form
covers the material presented
in the consent form in a more
age-appropriate language.)
____________________________________
Parent/Guardian/Custodian signature
_____________
Date
Relationship to minor (Check):
___ Mother ___ Father ___ Legal Guardian
Provide signature line for witness
__________________________
Witness
__________
Date
I have explained and defined in detail the
research procedure in which the subject has consented
to participate. Having explained this and answered any
questions, I am cosigning this form and accepting this
person’s consent.
Provide Signature and
Date lines for the principal
investigator
____________________________________
Principal Investigator
__________
Date