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Sample Informed Consent

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Remelie Robles
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12 views

Sample Informed Consent

Uploaded by

Remelie Robles
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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INFORMED CONSENT

Title:

Proponent:

DESCRIPTION: Write a description of your study, specifically its objectives.

Procedure: Write the data-gathering procedure, including the process of seeking consent. Include the number
of participants and duration of their participation. As well as include the responsibilities of the participants.

Potential Risks and Discomforts:


There is no risk in taking part in this study.

Potential Benefits:
This study will be deemed beneficial to the ……

Cost Compensation:
There is no cost nor payment for participation in this survey.

Confidentiality:
The researcher will follow ethical guidelines when conducting this study. The participant’s full consent will be
obtained before the study is carried out, the confidentiality of the research data will be guaranteed, biases and other
misleading information will be avoided, and other works and studies used in this study will be properly cited.

Voluntary Participation:

The participation in the study is completely voluntary. There is no penalty for not participating. You may
also refuse to answer any of the questions we ask you.

Right to withdraw from the study:


You are free to join the survey or not and will receive the same care regardless of your decision. If you decide
to join the survey, you are also free to change your mind at any time for any reason. There is no penalty for declining to
participate and you can decline without having to provide a reason.

I voluntarily agree to participate in this survey

Yes

No
I understand that I will be given a copy of this signed Consent Form.

Name of Participant (print):

Signature: Date:
Name of Witness (print):

Signature: Date:
Person Obtaining Consent (print):

Signature: Date:
Note: A copy of the signed, dated consent form must be kept by the Principal Investigator(s) and a copy must be
given to the participant.

Whom to contact if you have questions about the study:


Persons to contact: Name of proponent and phone number

If you have any questions about your rights as a participant in this survey or if you want to withdraw from this
survey at any time, you may email email of proponent

The Review Panel has approved the study and may be reached through the following contact for information
regarding the rights of study participants, including grievances and complaints: email add

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