Consent Form for Participation in Research
Project Title: ___________________
You are being invited to be interviewed by [INTERVIEWER’S NAME] from the Willamette
University Department of [INTERVIEWER’S DEPARTMENT. The purpose of this interview is to
provide information as part of a research project on [PROJECT TOPIC]. The following information is
provided to help you decide whether or not you would like to participate in this study. You are free to
decide not to participate or to withdraw at any time during the course of the study. Declining to
participate will not involve any negative consequences and will not affect your relationship with me or
with Willamette University.
The purpose of this study is to gather information about [PROJECT TOPIC]. Data will be collected
during the time period of [DATES].
Participants in the study will take part in an individual interview that should last approximately
[INSERT TIME]. The interview will be tape-recorded and written notes taken.
The final report relating to this project will take the form of a written paper accompanied by an oral
presentation for Willamette University students and faculty. This paper may potentially be submitted
for publication at a later date.
If you do NOT want your name to be used in my final report, please check the following box, and
your confidentiality will be protected:
If you do not check the box, you are giving permission for me to use your name when I create my
final report.
For any persons requesting confidentiality, tape recordings and notes relating to their interview will be
kept in a locked cabinet accessible only to the researcher until the project is completed. Upon
completion of the project any materials with identifying information about the participant will be
destroyed.
There are no expected risks associated with this project. I do not anticipate that the subject matter of the
interview to cause distress, but you are free to choose not to answer any questions, to change the subject
or to discontinue this interview at any time.
Expected benefits for participants include the opportunity to share one’s story and viewpoints and to
have that shared with others via this project.
Please feel free to ask any questions you may have. Questions about the research or research-related
issues should be directed to [INTERVIEWER’S NAME], at [CONTACT PHONE]. Questions about
your rights as a research subject may be directed to Dr. Meredy Goldberg Edelson, Chair, Willamette
University Institutional Review Board (phone: 503-370-6133, irbchair@willamette.edu).
Please sign below, acknowledging that you have read and understood the terms of this agreement,
purpose of this project and your consent to participate in it. You will be provided a copy of this form to
keep.
_______________________________________________
Signature of Participant
__________________
Date
Please check the box if you would like to receive a copy of the final report of my project: