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Consent&Confidentiality

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OutlineonConsent&ConfidentialityinSocialResearch

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ResearchDesign
ResearchInstruments
HICSampleConsentForm
Sample:InformedConsentDocumentforanAnonymousSurvey
Surveys
Voluntaryconsent

IunderstandthatIamparticipatinginthisresearchvoluntarily.

Ihavetherighttorefuseparticipationatanytime.

ConfidentialityStatementsmayincludethefollowing

Iunderstandthatanyinformationregardingmyidentityobtained

inconnectionwiththisresearchwillremainconfidential.
Iwillnotwritemynameorotherwiseindicatemyidentityon

anypartofthisresearch.
AuthorizationStatementsmayincludethefollowing

Ingivingmyconsentbysigningthisform,Iagreethatthemethods,inconveniences,risks,

andbenefitshavebeenexplainedtomeandmyquestionshavebeenanswered.
IunderstandthatImayaskquestionsatamytimeandthatIamfreetowithdrawfromthe

studyatanytimewithoutcausingbadfeelings.
Myparticipationinthisresearchmaybeendedbytheinvestigatororbythesponsorfor

reasonsthatwouldbeexplained.
Anyinformationdevelopedduringthecourseofthisstudywhichmayeffectmy

willingnesstocontinueintheresearchwillbegiventomeasitbecomesavailable.
IunderstandthatthisconsentfromwillbefiledinanareadesignatedbytheHuman
SubjectsCommitteewithaccessrestrictedtotheprincipleinvestigator######or

authorizedrepresentativeoftheDepartment.
IntroductoryStatement

Beforeanysurvey,intervieworotherResearchInstrumentcanbeadministered,
&beforetheConfidentialityStatementispresentedforassent,

anIntroductoryStatementmustbegiventothepotentialSubject

Introlettershouldpttotheimpoftheresearch
&appealshouldappealtorespondents'altruism
Suchanappealismoreeffectivethanimplyingthattherespondent
hassomethingtogainbyansweringthequestionnaire
Inclusionofa"reward"apenorsmallamountofmoneyimproves
rateofresponsemorebecauseitisatokenofresearcher's
appreciationthanbecauseofitsintrinsicvalue

https://people.uvawise.edu/pww8y/Resources/MERes/ResDesign/ConsentConfide.html

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SAMPLEINFORMEDCONSENTFORM
PrincipalInvestigator:Phone:
FacultySupervisor:Dr.PatrickWithenPhone:2763764526
HumanInvestigationsCommiteeChair:Dr.JimHortonPhone:2765555555
DepartmentofSocialSciences,UVaWise,1CollegeAve.,Wise,VA,24293
ProjectTitle:
ExpectedDuration:Thissurveyshouldtaketocomplete.
PurposeandBackground:Youareinvitedtoparticipateinastudyof(statewhatisbeing
studied).I,SampleStudent,amconductingthisresearchbecauseofmyinterestinthisarea,andas
partofmySeniorCapstonePorjectinSociology,whichisarequirementforgraduationfrom
UVaWise.Iamexamining(statewhatthestudyisdesignedtodiscoverorestablish.Insertan
santizedversionofyourthesisstatementhere.).Youwereselectedasapossibleparticipantinthis
studybecause(statewhyandhowthesubjectwasselected
Procedures:Ifyoudecidetoparticipate,I(yourname)will(describetheprocedurestobe
followed,includingtheirpurpose,howlongtheywilltake,andtheirfrequency.)
Risks/Discomforts:Therearenomeasurablepotentialrisksordiscomfortsinvolvedinthissurvey
otherthananxietycausedbythesurveyquestions.
(Describethediscomfortsandinconveniencesreasonablytobeexpectedaswellasanestimateofthe
totaltimerequired.Describetherisksreasonablytobeexpected.Anystandardtreatmentthatis
beingwithheldmustbedisclosed.)
Benefits:Theremaybenodirectbenefittoyoufromparticipatinginthisstudy.However,the
informationthatIprovidemayhelphealthprofessionalsbetterunderstandhow(whatyouexpectto
learnfromyourstudy.)(Describeappropriatealternativeproceduresthatmightbeadvantageousto
thesubject,ifany.)
Confidentiality:Anyinformationthatisobtainedinconnectionwiththisstudyandthatcanbe
identifiedwithyouwillremainconfidentialandwillbedisclosedonlywithyourpermission.(Ifyou
willbereleasinginformationtoanyoneforanyreason,youmuststatethepersonsoragenciesto
whomtheinformationwillbefurnishedandthenatureoftheinformationtobepurposed,andthe
purposeofthedisclosure.)
Costs:(Ifthereisapossibilityofadditionalcoststothesubjectbecauseofparticipation,describe
it.)
Payment:(Ifthesubjectwillreceivecompensationoranyotherbenefit,describetheamountor
nature.)
Consent:Yourdecisionwhetherornottoparticipatewillnotaffectyourfuturerelationshipswith
(institutionoragency).Ifyoudecidetoparticipate,youarefreetodiscontinueparticipationatany
timewithoutaffecting(yourtreatment,yourcare,youractivities,yourrelationship).
Questions:Ifyouhavequestions,pleaseaskus.Ifyouhaveanyadditionalquestionslater,
(investigatorsname)willbehappytoanswerthem.Ifforsomereasonyoudonotwishtodothis,
youmaycontacttheChairoftheHICKathleenHuttlinger,SmiddyHall,room243.
Youwillbeofferedacopyofthisformtokeep.
PARTICIPATIONINRESEARCHISVOLUNTARY.Youarefreetodeclinetobeinthisstudy,or
towithdrawfromitatanypoint.Yourdecisionastowhetherornottoparticipateinthisstudywill
havenoinfluenceonyourpresentorfuturestatusasa(patient,student,employee).
Youaremakingadecisionwhetherornottoparticipate.Yoursignatureindicatesthatyouhaveread
theinformationprovidedaboveandhavedecidedtoparticipate.Youmaywithdrawatanytime
aftersigningthisformshouldyouchoosetodiscontinueparticipationinthisstudy.
https://people.uvawise.edu/pww8y/Resources/MERes/ResDesign/ConsentConfide.html

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_____________________________________________________________________
SignatureDate
____________________________________________________________________
(SignatureofParentorLegalGuardian)Date
(Thislineshouldnotappearonformsthatwillbegiventosubjectsconsentingforthemselves.)
___________________________________________________________________
SignatureofWitness(whenappropriate)Date
___________________________________________________________________
SignatureofInvestigatorDate
TheEnd

https://people.uvawise.edu/pww8y/Resources/MERes/ResDesign/ConsentConfide.html

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