Survey Example-Informed Consent form

Project Title:
Project Director:
Participant's Name: What is the study about?
This is a research project. It aims at identifying best teaching practices by understanding
practices and beliefs of students and teachers.
Why are you asking me?
You are being asked to participate in this study because you are a student or a teacher.
What will you ask me to do if I agree to be in the study?
You are asked to complete a survey. You may also be asked to participate in a follow up
interview, focus group discussions, or observation. The survey is expected to take about 10
Is there any audio/video recording?
There is no audio or video recording for the survey. Interviews, focus group discussions, and
observations will be audio or video recorded. Because your voice will be potentially identifiable
by anyone who hears the tape, your confidentiality for things you say on the tape cannot be
guaranteed although the researcher will try to limit access to the tape as described below.
What are the dangers to me?
The Institutional Review Board at Alma College has determined that participation in this study
poses minimal risk to participants. Your participation WILL NOT AFFECT GRADES for any
of your course.
Questions, concerns or complaints about this project or benefits or risks associated with being in
this study can be answered by
who may be contacted at:
How will you keep my information confidential?
All information obtained in this study is strictly confidential unless disclosure is required by law.
All data will be kept in a locked file cabinet and password protected computer. Your name will be
replaced by pseudonyms when data are disseminated.
Are there any benefits to society as a result of me taking part in this research?
Your participation in this study may inform the field of education on how to support K-16
Are there any benefits to me for taking part in this research study?
There are no direct benefits to participants in this study. However, participation in this study may
help you in becoming a reflective student or teacher. Your participation may also help educators
to create classroom environments that best support your education.
Will I get paid for being in the study? Will it cost me anything?
There are no costs to you or payments made for participating in this study.
What if I want to leave the study?
You have the right to refuse to participate or to withdraw at any time, without penalty. If you do
withdraw it will not affect you in any way. If you choose to withdraw, you may request that any
of your data that has been collected be destroyed unless it is in a de-identifiable state.
What about new information/changes in the study?
If significant new information relating to the study becomes available which may relate to your
willingness to continue to participate, this information will be provided to you.
Voluntary Consent by Participant:
By signing this consent form you are agreeing that you read, or it has been read to you, and you
fully understand the contents of this document and are willing to take part in this study. By
signing this form, you are agreeing that you are 18 years of age or older and are agreeing to
participate in this study.
Signature: ________________________ Date: ______________