CONCORDIA PSYCHOLOGY DEPARTMENT HUMAN ETHICS FORM
1.
CONTACT INFORMATION
Student Name
E-mail
Supervisor
E-mail
Other individuals supervising project
E-mail
Working Title (please keep the title to less than 12 words):
2.
SIGNATURE AND DECLARATION
I hereby declare that this form accurately describes the research project that I plan to
conduct.
ALL activity conducted in relation to this project will be in compliance with:
 The Tri Council Policy Statement: Ethical Conduct for Research Involving Human
Subjects, available here:
http://www.ethics.gc.ca/pdf/eng/tcps2/TCPS_2_FINAL_Web.pdf

The Concordia University Code of Ethics: Guidelines for Ethical Actions
Signature of Student:
Date:
________________________________________
____________________________
Supervisor’s Signature
Please have your supervisor tick the appropriate box, and sign the form.
1. The described project falls under the approval of the supervisor's current ethics approval,
and only requires the permission of the thesis course instructor. Enclose a photocopy of the
current human ethics certificate.
2. The described project is currently under review by the Concordia Human Ethics
Committee. The supervisor will email the thesis course instructor when approved.
Signature of Supervisor: ________________________________________
Date:
____________________________
Psychology Department Ethics Protocol Form
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Student Name
3.
PROJECT OUTLINE
b) Aims of project:
c) What will the participants have to do? (very brief outline of procedure; please draw attention to any
manipulation that could possibly be judged as deception (includes, but is not limited to, deliberate
presentation of false information; suppression of material information; selection of information designed to
mislead; selective disclosure of information.)
4.
RESEARCH PARTICIPANTS
a) Describe the group of people who will participate in this project (i.e., demographic, age range, gender,
clinical population, etc.). Also include the projected number of participants.
b) Describe how participants will be recruited.
c) What sort of stimuli or materials will your participants be exposed to? Tick the appropriate boxes and
then explain the form that they take in the space below, please draw attention to any content that could
conceivably upset your participants.
Questionnaires[ ]; Pictures/Movies[ ]; Sounds [ ]; Words[ ]; Caffeine[ ]; Alcohol[ ]; Other[ ].
Psychology Department Ethics Protocol Form
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5.
INFORMED CONSENT
Informed consent must be obtained for all participants before they take part in your project. The consent
form should clearly state what they will be doing; drawing attention to anything they could conceivably
object to subsequently. It should be in language that the person signing it will understand. It should also
state that they can withdraw from the study at any time and the measures you are taking to ensure the
confidentiality of data. If children are recruited, you will require the permission from the parents. Children
over 14 years should also sign an individual consent form themselves. Testing to be carried out in any
institution (hospital, prison, etc.) will require permission from the appropriate authority.
a) Please describe how you will obtain informed consent from your participants? From whom will you
seek permission? Include a copy of your consent form.
b) How will participants be informed that they are free to discontinue at any time?
6.
RISKS AND BENEFITS
What risks might occur in your research and at what level? Tick the appropriate box.
Type of risk
none
minimal
more than minimal
not sure
physical (pain, health effects, etc.)
psychological (emotional, behavioural,
stress, etc.)
sociological (employability, reputation, etc.)
loss of confidentiality (participant identified by
name in results, etc.)
criminal or civil liability
heinous discovery (child abuse, unknown
illness or condition, depression; etc,)
other (explain below)
For any response other than 'none' above, indicate below what safeguards will be used to eliminate or
reduce these risks? Include any “withdrawal” criteria.
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7.
DEBRIEFING AND DATA STORAGE
Debriefing - how and when will participants be informed about the experiment, and what information do
you intend to provide? If there is any chance that a participant will be 'upset' by taking part in the
experiment? What measures will you take to mitigate this?
What procedures will you follow in order to guarantee the confidentiality of participants' data? Will
participants have access to their data? Personal data (name, addresses, etc.) should only be stored if
absolutely necessary and then only in such a way that they cannot be associated with the participant's
experimental data.
Give brief details of other special issues that the ethics committee should be aware of.
Psychology Department Ethics Protocol Form
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