ࡱ> MOLy .bjbj 4B{{&0000,\$0($!~III:III:,1>.pX: m0RN"RN"11N"E(IIN" : Model Consent Forms There are 3 sample consent forms below to give an idea of how to obtain informed consent from research participants. The more risk involved in project, the more needs to be stated on the consent form. As most research we do does not involve risk to participants, these samples provide the basic, minimal statements that inform the participant of the nature of the study, their rights to not participate or withdraw their data, and costs and benefits, if any, of the participation. Please review the federal regulations concerning the content of consent forms:  HYPERLINK "http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html%2346.116" http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html#46.116 Sample 1: Experiment Grinnell College Janet M. Gibson, Michelle Briggs, Andrew Shaw Dept. of Psychology Summer, 2012 Time Management and Memory Consent Form In this study you are asked to complete a scale that measures time management abilities and tasks that measure both time management and memory-related processes. Some tasks will be on the computer and others will not. Furthermore, some will be timed, while others will not. Instructions for all the tasks will be given prior to each one, and you can take breaks in between tasks. There are no physical or psychological risks involved. Whether you have a good or not-so-good memory, your data are valuable. Performance on any one of these tasks does not necessarily reflect your memory abilities in general, as our ability to remember can change across various conditions (whether you had lots of sleep, etc.). We are looking for patterns across the tasks given todays conditions to help us examine the relationship between time management and memory. You may stop participating at any time, for any reason, without penalty. Your data are anonymously entered into the dataset, although if you wish to receive the results of your tests, I will need to match an ID number to your consent form. The consent forms are stored in our lab, and the datasets are stored on password-protected computer space. Names are not used in the data set. If we publically present the data, it will be in summary form only. Participants receive $10 for participating in this project. If you have any questions about the study, please feel to ask. After all the tasks are completed, we will give you a debrief form that describes the theory behind the scales and tasks and provides references of articles for further reading. We appreciate your participation in our research. Thank you! If you are 18 years of age or older and consent to participate in this study, please sign and print your name below. ____________________________________ ____________________________________ Written Signature Printed Name Also, for purposes of describing the demographics of the sample, please provide information about your sex, age, education level, and race. Age (in years, months: e.g., 19 y 8 mos): ______________________ Please Circle: Sex: Male Female Race: African-American American Indian Asian Caucasian (White) Other ________________________________________________________ Highest Level of Education (e.g., GED., High School Graduate, Bachelors Degree, etc.): ________________________________________________________________________ Contact Information (Only fill out if you wish to receive the results of your test; e.g., address, email): ________________________________________________________________________ Sample 2: Online Survey Consent Form Title of Study: Mental Health Attitudes Online Survey Investigator: Christopher A. Ralston, Ph.D. Scott Phillips INTRODUCTION The purpose of this survey is to help clarify how people think about themselves and others when deciding to seek help for mental health issues. You are invited to participate in an online survey about mental illness and mental health help-seeking attitudes. DESCRIPTION OF PROCEDURES You must be 18 years of age or older to participate. If you provide your name and click the I agree button on this page to confirm your participation in this study, you will be linked to the online survey. Your participation is completely voluntary and will last less than 60 minutes. Your name is requested only to provide course credit and will be stored in a separate database. Your name will not be connected in any way to your responses. At the completion of the survey, you will be offered an opportunity to participate in another, smaller survey in two weeks. The purpose of this second survey is to determine if the scales used produce consistent results. If you agree to participate in the second survey, you will receive an email in 12 days with an identification number assigned by the researchers, a link to the new survey, and an informed consent document describing this study and your participation rights. The time required to take the second survey is estimated to be less than 30 minutes. RISKS Though the risks of responding to the questions is minimal, it is possible that persons who have experienced or known someone who has experienced negative consequences of admitting to a mental illness or help-seeking may experience some feelings of distress by responding to the questions. Consequently, if you experience distress during your participation you do not have to continue participation. Also, if you experience personal distress you can receive free walk-in counseling services at Grinnell College Health Center, located in the basement of the Forum building (641-269-3230) This information will also be provided to you when you exit the survey. BENEFITS If you decide to participate in this study, there may be no direct benefit to you, except completion of course credit (One PSELL Credit for this survey and 0.5 PSELL Credits for the second, follow-up survey in two weeks). It is expected that the information gained in this study will benefit the scientific research community by providing an initial step in developing a comprehensive model of mental health and help-seeking. PARTICIPANT RIGHTS Your participation in this study is completely voluntary and you may refuse to participate or leave the study at any time. If you decide to not participate in the study or leave the study early, it will not result in any penalty or loss of benefits to which you are otherwise entitled. CONFIDENTIALITY Beyond your name and email address, no personally identifiable information will be required or requested within the survey. Your name will be stored separately from all other responses, and will not be connected to any of your responses on the survey. Your name is requested only to provide course credit upon completion. If you elect to participate in the second survey, your email address will be stored temporarily to provide you with a future email about the second survey. Your email address will be stored separately from your responses and not connected in any way to those responses. A randomly generated identification number will be used to match your previous responses to the responses from the second survey. Your email address will be deleted from the researchers records at the earliest of three time points: when you complete the second survey, when you inform the researchers you no longer wish to participate, or at the end of the semester for those that either do not participate or do not inform the researchers that they no longer with to participate. After that time, all other responses will be kept anonymous, and the code numbers provided by the researchers will not be linked to you in any way. All responses will be kept in an electronic database in the locked lab of Dr. Ralston and will be destroyed at the completion of the study, a period not to exceed seven years. Only the researchers of this experiment will have access to the responses. If the results are published, your identity will remain confidential. QUESTIONS OR PROBLEMS You are encouraged to ask questions at any time during this study. Please direct questions to Dr. Christopher Ralston, 1605 in Noyce Science Center, Grinnell College, Grinnell, IA Phone: 641-269-4836 Email:  HYPERLINK "mailto:ralstonc@grinnell.edu" ralstonc@grinnell.edu. Contact for the Grinnell College Institutional Review Board: irb@grinnell.edu.  Sample 3: Oral Consent Script (from Brigittine Frenchs project) Oral Consent Form Thanks for agreeing to talk with me. As I mentioned before, I am a professor of Anthropology at Grinnell College in the United States. Im doing some research about the importance of Arensberg and Kimballs studies of Co. Clare in the 1930s and about the relevance of the past and cultural traditions in the present for Co.Clare citizens like yourself. Id like to ask you some questions about these topics. There are no risks involved and your participation is completely voluntary. If you dont want to answer a question, please let me know and well move on to another. If at any time you decide you dont want your perspective included in my study, you can let me know at the end of the interview or by contacting me later via e-mail, letter, or phone at the contact information on my card. Your answers and identity will be protected by pseudonyms, unless you tell me you would like to be specifically identified in the study. After I have completed the research, I will present papers about my findings at conferences primarily in the United States, Ireland and United Kingdom as well as publish articles in scholarly journals about these topics. I will be happy to send you a copy of any written publications if you would like. 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