SURVEY INFORMATION/ IMPLIED CONSENT
TEMPLATE
Italicized text is instructional, providing information to the information sheet writer. It should be
deleted when writing the information sheet. The remainder of the text is mandatory. Ensure the
information sheet is written in the second person throughout the whole document (except the
headings).
To ensure confidentiality, start the questionnaire on a separate page.
TITLE: The full title of the research project goes here.
INVESTIGATORS: Include the name of the Principal Investigator followed by the names of
any co-investigators
SPONSOR: Put the name of the organization/company providing funds and/or equipment here.
This information sheet is only part of the process of informed consent. It should give you the
basic idea of what the research is about and what your participation will involve. If you would
like more detail about something mentioned here, or information not included here, please ask.
Take the time to read this carefully and to understand any accompanying information.
BACKGROUND
This section of the consent form is for describing the rationale for the study, its design and
methods. Please use lay language,
WHAT IS THE PURPOSE OF THE STUDY?
Provide a statement describing the purpose of the study. Be concise.
WHAT WOULD I HAVE TO DO?
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Ethics ID:
Study Title:
PI:
Version number/date:
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CHREB Template last edited March 2015
Describe exactly what the research will involve for the subject. Include the frequency and
number of surveys/questionnaires. Estimate how much time this may take, and if there is any
follow-up.
WHAT ARE THE RISKS?
List all likely risks of the study (e.g., are any of the questions potentially upsetting? Will
participants be asked to provide information about criminal activity that might put them at risk if
confidentiality is not maintained?)
WILL I BENEFIT IF I TAKE PART?
Describe the probability and nature of direct and indirect benefits to the subjects themselves and
to others. Be objective.
DO I HAVE TO PARTICIPATE?
Explain that participation in this study is voluntary and they may withdraw from it at any time. If
there are limits to withdrawal (i.e., data captured anonymously), please explain. Also explain
that the researcher can withdraw them from the study.
WHAT ELSE DOES MY PARTICIPATION INVOLVE?
This is the section in which to describe any unique features of the research that have not already
been discussed and may affect the subjects. This section can be omitted if not applicable.
WILL I BE PAID FOR PARTICIPATING, OR DO I HAVE TO PAY FOR ANYTHING?
Describe any costs subjects may incur as a condition of or because of participation in this study.
State if any incentives or honoraria (e.g., gift cards etc.) will be provided
WILL MY RECORDS BE KEPT PRIVATE?
Explain who will have access to information collected and to whom, if anyone, the identity of the
subject will be disclosed.
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Ethics ID:
Study Title:
PI:
Version number/date:
Page expressed as X of Y
CHREB Template last edited March 2015
Describe data security and privacy protections, including where the data will be held.
If you are using a web-based survey administration tool (e.g., Fluid survey, Survey Monkey),
describe the location, security and privacy protects/limitations of the company’s server An
example of a typical statement is:
“This online survey company is hosted by a web-survey company located in the USA and
as such is subject to U.S. laws. In particular, the US Patriot Act which allows authorities
access to the records of internet service providers. This survey or questionnaire does not
ask for personal identifiers or any information that may be used to identify you. The websurvey company servers record incoming IP addresses of the computer that you use to
access the survey but no connection is made between your data and your computer’s IP
address. If you choose to participate in the survey, you understand that your responses to
the survey questions will be stored and accessed in the USA. The security and privacy
policy for the web-survey company can be found at the following link: ________
AGREEMENT TO PARTICIPATE
Your decision to complete and return this survey will be interpreted as an indication of your
agreement to participate. In no way does this waive your legal rights nor release the
investigators, or involved institutions from their legal and professional responsibilities. You are
free to withdraw from the study at any time.
If you have further questions concerning matters related to this research, please contact:
Dr. ___________ (403) ___-____
or
Dr. ___________ (403) ___-____
If you have any questions concerning your rights as a possible participant in this research, please
contact the Chair of the Conjoint Health Research Ethics Board, Research Services, University
of Calgary, 403-220-7990.
The University of Calgary Conjoint Health Research Ethics Board has approved this research
study.
Before submitting your consent form, please check it over for grammar, spelling and typing
errors.
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Ethics ID:
Study Title:
PI:
Version number/date:
Page expressed as X of Y
CHREB Template last edited March 2015