Word file - Psychology

Informed Consent
Please read this consent agreement carefully. You must be 18 years old or older to participate.
Purpose of the research:
Example: [To examine how people perceive and remember visual displays.]
What you will do in this study:
Example: [You will view displays on a computer monitor and provide responses (in writing or by pressing
keys on a computer keyboard). The displays may be arrays of letters, simple shapes or objects, photographs,
or movies. You might also make predictions about how you or other people might do in performing a given
task. While you are viewing the displays, we will use an eye tracker to measure where you are looking.]
There are no anticipated risks, beyond those encountered in daily life, associated with participating in this
study. Additional risk info here, or leave blank if no anticipated risks. Example: [The task is attention
demanding, so you might experience some fatigue as a result of participation.].
The study will take under 50 minutes to complete. You will receive 1 course credits (1 subject pool hours)
for participating in this study. This study requires attendance at more than one session; you will receive
credit only after completing the final session. At the end of the study, you will receive an explanation of the
study and the hypotheses. We hope that you will learn a little bit about how psychological research is
Voluntary Withdrawal:
Your participation in this study is completely voluntary and you may withdraw from the study at any time
without penalty. You will not receive Psychology credit unless you complete the experiment or participate in
at least 50 minutes. You can receive credit for completed hours (1 credit for 50-110 minutes, 2 credits for
greater than 110 minutes) if you fill out an Early Withdrawal Form. You may skip any questions or
procedures, or you may withdraw by informing the research associate that you no longer wish to participate
(no questions will be asked) or, if in case you decide to stop participation in this study at a later time (between
sessions), you can fill out this form at the Subject Pool Coordinator’s Office (Room 305, Psychology
Building). Your decision to participate, decline, or withdraw participation will have no effect on your status at
or relationship with the University of Illinois.
Your participation in this study will remain confidential, and your identity will not be stored with your data.
Your responses will be assigned a code number that is not linked to your name or other identifying
information. All data and consent forms will be stored in a locked room. Results of this study may be
presented at conferences and/or published in books, journals, and/or in the popular media.
Further information:
If you have questions about this study, please contact
, Department of Psychology, University of
Illinois, Champaign, IL 61820. Email:
; phone: (217)
Who to contact about your rights in this study:
If you have any concerns about this study or your experience as a participant, you may contact the
Institutional Review Board (IRB) at UIUC at (217) 333-2670 (collect calls will be accepted if you state you
are a study participant); email: [email protected]
The purpose and nature of this research have been sufficiently explained and I agree to participate in this
study. I understand that I am free to withdraw at any time without incurring any penalty. I understand that
I will receive a copy of this form to take with me.
Signature: ________________________________
Date: __________________
Name (print): _____________________________
IRB-approved template, 12-29-2005