SAMPLE INFORMED CONSENT FORM
I am an undergraduate student at York University. My name is Ann Undergrad and I can
be contacted at anundergrad@yorku.ca
I am taking the course EXAMPLE 1001. As a course requirement, I am working on a
project whereby I need to collect information on how people/students (may contain a
population qualifier) perceive/feel about (group/policy/event x.) I am therefore asking if
you would agree to participate in my research by answering a questionnaire.
The questionnaire has (10-20) questions and should take about (5) minutes to complete.
You do not have to participate at all, or, even if you agree now, you can terminate your
participation at any time without prejudice. You also do not have to answer individual
questions you don’t want to answer. Your name will not be attached to the questionnaire
and I will ensure that your participation remains confidential. (This consent form will be
kept separate from the questionnaire for all participants.)
I can tell you that your response may be included in the paper I will write at the
conclusion of this assignment; however, your responses would be anonymous and
nobody could connect your responses with you as an individual.
A benefit you may experience by participating in this study is greater knowledge of your
perceptions/feelings about (event x).
By participating in this study, you risk being upset or made uncomfortable by the
questions asked.
If you have any questions or concerns, please feel free to contact me at
anundergrad@yorku.ca or my professor, Dr. Alex Smith at asmith@yorku.ca. (Note that,
if you do participate, you will receive a separate sheet of paper with my and my
supervising professor’s contact information on it to take away with you.)
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Participant signature
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Date
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Researcher Signature
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Date