The Center for Service Learning (CSL) is interested in using your project— Digital Story—submitted as part of the Sam H. Jones Scholarship program. To this end, we ask you to grant the CSL permission to use your submissions for multiple purposes. Your submissions will be used to assess and inform service scholarship programming and the impact of your scholarship work on your continued civic growth and development. In addition, the digital stories may be used in marketing related to CSL’s work and in scholarly presentations.
SUBJECT’S CONSENT:
Please consider the multiple ways in which your Digital Story might be used. Place an “X” in the box if you give CSL consent for its use. You will be given a copy of this informed consent document to keep for my records if requested. I agree to take part in this study.
By placing an “X” in the box you give CSL permission to use your Digital Story and have read the informed consent document.
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Research: CSL is continually engaged in research to understand the ways a service-based scholarship program may contribute to the development of student civic-mindedness. To this end, we evaluate various interventions/activities designed to encourage student growth. The project you submitted for the Sam H. Jones Scholarship is one of many activities students may be engaged in while at IUPUI and we are interested in learning about your reflections and consequent civic growth.
Therefore, CSL would like to have your permission to access your project beyond the scholarship requirements.
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Marketing: CSL is interested in gathering various types of information for a communication and marketing initiatives. CSL would like your permission to use the Digital Story you created for the CSL website and other marketing materials as a way of highlighting the scholarship program and the impact
CSL has on students engaged in our programs.
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Scholarly Activity: CSL continues to be a leader within the service learning and civic engagement discipline and to this end, we engage in conferences and other professional development opportunities in which we have an opportunity to demonstrate our efforts to others in similar positions. Although this work may or may not result in publication, we would like to be able to share your submissions with others in the discipline as a way to encourage, challenge, and support the work on other campuses.
CONFIDENTIALITY:
Efforts will be made to keep your personal information confidential. However, we cannot guarantee absolute confidentiality. Aspects of your digital story may also reveal your identity (e.g., your pictures) and we wish to share your digital story in publications and presentations. We will only use the information contained in your digital story and poster presentation for research purposes and databases in which your work is stored will be secured and password protected.
Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the IUPUI/Clarian

Institutional Review Board or its designees, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP).
BENEFITS OF TAKING PART IN THE STUDY:
The benefits to participation include the fact that you and other students may benefit by improved educational interventions and processes. We will be using this research to better understand how various interventions impact civic learning. We also plan to use the results of this research to make any necessary improvements to the reflection prompts as well as the process of creating digital stories for all students.
ALTERNATIVES TO TAKING PART IN THE STUDY:
The only alternative is not participating in this study and not having your assignment submissions reviewed for program improvement processes.
CONTACTS FOR QUESTIONS OR PROBLEMS:
For questions about the study or a research-related injury, contact the researcher Kristin Norris
( norriske@iupui.edu
, 278-0013). If you cannot reach the researcher during regular business hours (i.e.
8:00AM-5:00PM), please call the IUPUI/Clarian Research Compliance Administration office at (317) 278-
3458 or (800) 696-2949. After business hours, please call 317-652-1685.
For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the IUPUI/Clarian Research
Compliance Administration office at (317) 278-3458 or (800) 696-2949.
VOLUNTARY NATURE OF STUDY:
Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with
IUPUI.
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I have read the information above, indicated the ways in which I authorize CSL to use my information, and AGREE to participate.
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DO NOT AGREE TO PARTICIPATE
Print Name: ____________________________________
Major: ____________________________________ School: _________________________________
Signature: _________________________________________________ Date:_____________