Informed consent form
Title of the research project:
XXX (research project funded by XXX)
Research Team :
First name, Family name of student
Master’s/Ph.D. degree candidate
Polytechnique Montréal
C.P. 6079, succ. Centre-ville
Montreal, Quebec
H3C 3A7
Phone : (514) XXX-XXXX
Fax : (514) XXX-XXXX
E-mail : xxxxxxxx@polymtl.ca
First name, Family name of supervisor
Polytechnique Montréal
C.P. 6079, succ. Centre-ville
Montreal, Quebec
H3C 3A7
Phone : (514) XXX-XXXX
Fax : (514) XXX-XXXX
E-mail : xxxxxxxx@polymtl.ca
First name, Family name of co-supervisor (if any)
Polytechnique Montréal
C.P. 6079, succ. Centre-ville
Montreal, Quebec
H3C 3A7
Phone : (514) XXX-XXXX
Fax : (514) XXX-XXXX
E-mail : xxxxxxxx@polymtl.ca
Preamble:
We hereby request your participation in a research project aimed at XXX. You have been
selected for this project because [reason for which you are targeting this participant].
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However, before accepting to participate in this project and before signing this form, please
take the time to read, understand and carefully consider the information provided below.
We invite you to ask any question you might have to the researcher in charge of the project
or the other members of the research team and to ask them to explain to you any word or
information that is not clear.
Presentation of the research project and its objectives:
The objectives of this study are as follows: i) XXX, ii) XXX and iii) XXX.
In order to reach our objectives, we will [describe each of stage of your project in clear and
simple terms]. Indicate what you hope to demonstrate, which are your hypotheses and what
the participants will have to do.
Nature and duration of your participation in this research project:
For researchers wishing to pass out a questionnaire: your participation within the scope of
this project will consist in a series of questions to which you will be asked to answer based
on your knowledge and experience in the field of XXX. All the answers you will provide will
remain confidential. Completing the questionnaire will take approximately XX minutes. If you
accept to participate in this project, simply fill out the attached questionnaire and return in
to [e-mail address]/hand it out to one of the research team members OR simply fill out the
questionnaire at the following URL.
For researchers wishing to conduct an interview: Describe the way the interview will be
carried out. Precise the anticipated duration of the interview, where it will take place etc. If
after further consideration you decide to participate in this project, please sign this form and
hand it out to one of the research team members.
For researchers wishing to conduct a test: Describe what the participant will need to do (e.g.
run at a certain speed, 5mn break, jump sideways, undergo an x-ray in XX position…). If
after further consideration you decide to participate in this project, please sign this form and
hand it out to one of the research team members.
For all types of research, please indicate the inclusion/exclusion criteria [e.g. Within the
scope of this project, only men aged between XX and XX and suffering from XX will be
included in the study, you need to be 18 years or older and to have 3 years experience in XX
to participate in this study, you should not have any history of XX to participate in this
study].
Benefits resulting from your participation in the research project:
Indicate the personal benefits which can be anticipated by the participants to the study.
Should there be no direct benefit, please indicate that: you will not derive any personal
benefit from your participation to this research project. However, the knowledge acquired
through your participation will XXX [advance the state of knowledge on XXX, improve XXX].
It is customary to provide the conclusions of the master’s or Ph.D. thesis to the participants
to thank them for their participation.
Disadvantages resulting from your participation in the research project:
List the disadvantages which could result from the research project [e.g. your participation
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to the research project will require XX minutes of your time to XXX, the research project
could cause some dizziness, stress, discomfort, fatigue, rashes…]
Risks resulting from your participation in the research project:
In the case of a questionnaire: This research project will not subject you to any additional
risk than those you are subject to in your regular daily activities. You could potentially find it
difficult to answer some questions. If so, feel free not to answer these questions.
In the case of an interview/a test: This research project entails low risks of XX [e.g. falling,
fatigue…]. [The risks can be social, behavioral, psychological, physical or economic in
nature]. In order to minimize the probability that XXX happens, we will ask you to XXX
[Indicate the measures that will be taken by the researchers to minimize the risks resulting
from the research project].
Financial compensation:
You will not receive any financial compensation for your participation in this study OR You
will receive a $XX compensation for your participation in this study [e.g. XX per visit, $XX
reimbursement of travel expenses]. Indicate what will happen should the participants decide
to withdraw from the study during the course of the study.
Compensation in case of prejudice and rights of the participant :
Should suffer any prejudice as a result of your participation in this project, be informed that
you are not giving up any of your rights nor discharging the researchers, the granting
agencies or the institution from their legal and professional duties.
Voluntary participation and withdrawal:
In the case of a questionnaire: Your participation in this research project is voluntary. You
can therefore refuse to participate in it by not answering the questions of the following
survey.
In the case of an interview/a test: Your participation in this research project is voluntary.
You can therefore choose to withdraw from it at any time without having to motivate your
decision nor suffering any prejudice [Indicate what will happen should the participants
decide to prematurely withdraw from the project with regards to the data already collected,
their financial compensation etc.].
Participants may be withdrawn without their consent by the researchers or the Research
Ethics Board of Polytechnique Montréal should they not follow the instructions provided or
should there be some administrative reasons to abandon the project, notably for safety or
feasibility reasons.
Confidentiality:
In the case of a questionnaire: Upon receipt of the survey duly filled, the researcher in
charge of the project will compile the answers to the questions asked. Only the information
that is needed for the safe execution of the research project will be collected. This
information could include information about your position, your experience in the field of
research, the kind of institution or company you are working for or the country you are
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practicing in.
In the case of an interview: During your interview the researcher in charge of the project will
compile the answers to the questions asked. Only the information that is needed for the safe
execution of the research project will be collected. This information could include information
about XX, XX and XX.
In the case of a test: During the test you will be participating in the researcher in charge of
the project will XXX [Describe what the participant will have to do]. Only the information
that is needed for the safe execution of the research project will be collected. This
information could include information about XX, XX and XX.
All the information collected within the framework of this study will remain strictly
confidential within the legal limits. In order to preserve your identity and the confidentiality
of the information you will provide us with, we will assign a code to you. The data collected
by the researcher in charge of the project will be kept and locked up in his/her office at
Polytechnique Montreal.
The researcher in charge of the project will use all the data for the sole objectives
research project briefly described above. The data collected within the framework
project could be published in scientific papers or be shared with other people
scientific conferences. However no information that could lead to your identification
contained in these publications or scientific communications.
of the
of the
during
will be
For monitoring or control purposes your research file could be consulted by a person
mandated by the Research Ethics Board of Polytechnique Montreal or by a person mandated
by the research councils. All these individuals adhere to strict confidentiality policies.
You are entitled to consult your research file to verify the correctness of the collected
information for as long as the researcher in charge of the project and the institution possess
this information. However, to preserve the scientific integrity of the research project, you
will have access to this information only at the termination of the study.
The collected data will be kept for a 7-year period, after which it will be destroyed.
Contact people:
Should you have any questions pertaining to the research project, you can communicate
with XXX, researcher in charge of the project at: (514) 340-4711, Ext. XXX or by e-mail at:
xxx.xxxxxx@polymtl.ca.
Should you have any questions pertaining to your participation in this research project, you
can communicate with Ms. Farida Cheriet, Chair of Polytechnique Montreal’s Research Ethics
Board at: (514) 340-4711, Ext. 4277 or by e-mail at: farida.cheriet@polymtl.ca.
Consent:
In the case of a questionnaire: By answering the questions in the attached
questionnaire/questionnaire available at the following URL, you agree to participate in this
research project in accordance with the conditions set out in this document. Please keep a
copy of this document.
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For other types of studies: I have carefully read this document. I was clearly explained what
my participation consisted in. A member of the research team answered all my questions
and I was given enough time to decide whether I wanted to participate in this study or not. I
hereby agree to participate in this research project in accordance with the conditions set out
in this document. I have received a copy of this document.
_________________________________ _____
Name and signature of the research participant
____________________________
Date
I hereby certify that I have carefully explained the participant what his/her participation will
consist in. I have answered all his/her questions pertaining to this project and clearly
mentioned to him/her that he/she remains entitled to withdraw from the project at any time
without suffering any prejudice. I hereby certify that my research team and I will respect all
the conditions set out in this document and attest having given a copy of this document to
the participant.
_________________________________
Name and signature of the researcher
____________________________
Date
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