(insert department name)
Title of Project:
(insert project title)
Investigators:
(insert the investigators names, affiliation, contact information)
(In the first paragraph of the information sheet provide information about the course and the
activities that are a requirement of the course, particularly those that are course activities that you
would like to evaluate.)
Professor (insert course instructor’s name) would also like to use the information you provide in the
context of ABCDXXXX (i.e., course number) in her/his evaluation research. The evaluation research
concerns (insert the focus of the evaluation). Specifically, and with your written consent Professor
(insert name) would like to use the following activities from the course in her/his evaluation research:
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Activity 1
Activity 2
Activity 3
Activity 4 which involves audio and video recording of course activity (note: the audio and video
recordings are used in class, for say, demonstrating characteristics of activities)
Etc.
In addition, if you are interested, you may be invited to participate in a one-hour video recorded
interview to discuss your own experience with the (insert course activity being evaluated). The followup interview will be conducted by Professor (insert name) once the course grades have been submitted.
With your agreement, quotations recorded during the interview will be used but will remain anonymous
in any presentations, reports, and publications.
If you permit the use of (insert activities with text, such as journals, audio recordings) in the evaluation
research, the quotations used will remain anonymous in any presentations, reports, and publications.
You are under no obligation to provide your consent for information provided in the context of
ABCDXXXX to be used in the evaluation research. Further, a decision to participate or not will have no
impact on your grade in ABCDXXXX. Ms/Mr./Professor (insert name of person not involved in
conducting the course) will collect student consent forms and place in a sealed envelope. Consent
forms will be retained by Ms/Mr./Professor (insert name). Professor (insert course instructor’s name)
will not receive these or be able to make use of any of the course information for her/his evaluation
research until after the final grades have been submitted to ensure that until that point, she does not
know who has agreed that she/he can use their information in her/his evaluation research and who has
not. You may decide to withdraw from this study at any time by advising Ms/Mr./Professor (insert
name of person retaining consent forms) and may do so without any penalty. A decision to participate
in this evaluation study or not, or a later decision to withdraw agreement will have no consequence on
your standing in the course. Ms/Mr./Professor (insert name of consent form holder) can be contacted
at 519-888-4567 extension xxxxx or through email at xyz@uwaterloo.ca.
All information you provide is considered completely confidential; indeed, your name will not be written
on, or in any way associated with the data collected in this study. Data and recordings used in this
evaluation study will be retained for three years in a locked room in the (insert name) department to
which only the researcher has access and then will be confidentially destroyed. There are no known or
anticipated risks associated with participation in this evaluation study.
This project has been reviewed and received ethics clearance through a University of Waterloo Research
Ethics Committee. If you have any questions or concerns resulting from your participation in this study,
please contact Dr. Maureen Nummelin, the Director, Office of Research Ethics, at 1-519-888-4567, Ext.
36005 or maureen.nummelin@uwaterloo.ca.
Thank you for your assistance with the project.
CONSENT TO PARTICIPATE
I have read the information presented in the information sheet about an evaluation study being
conducted by Professor (insert name) of the Department of (insert name) at the University of Waterloo.
I have had the opportunity to ask any questions related to this evaluation study, to receive satisfactory
answers to my questions, and any additional details I wanted. I am aware that I may withdraw from the
study without penalty at any time by advising Ms/Mr./Professor (insert name of person retaining
consent forms) at 519-888-4567 extension xxxxx of this decision.
This project has been reviewed by and received ethics clearance through a University of Waterloo
Research Ethics Committee. I was informed that if I have any comments or concerns resulting from my
participation in this study, I may contact the Director, Office of Research Ethics at 519-888-4567
extension 36005.
With full knowledge of all foregoing, I agree, of my own free will, to participate in this evaluation study.
___ Yes ___ No
I agree that my activity x can be used for evaluation purposes
___ Yes ___ No
I agree that audio recordings of activity y can be used for evaluation purposes
___ Yes ___ No
I agree that video recordings of activity y can be used for evaluation purposes
Name: ________________________________________
Signature: ________________________________________
Date: ___________________________
Witness Signature: _________________________________