Copy the following form and modify to fit your needs. Add space as needed. Electronic (e-mail) submission of materials to the IRB is preferred. Research that involves children (persons under the age of consent) require that both the parent and the child sign consent forms.
Informed Consent Agreement
Please read this consent agreement carefully before you decide to participate in the study
Project title: Media and Body - Esteem
Purpose of the research study: The purpose of this study is to investigate the relationship between our perception of our body and the types of media to which we are exposed.
What you will do in the study: You will be asked to answer an eight-question test. You will also be asked to attend a slideshow presentation of media images.
Time required: Including the time for the pretest the entire procedure will only take 20 minutes.
Risks: There are no risks.
Benefits: There are no direct benefits to you for participating in the study.
Confidentiality: The information that you give in the study will be handled confidentially. Your information will be assigned a code number. The list connecting your name to this number will be kept in a locked file. When the study is completed and the data have been analyzed, this list will be destroyed. Your name will not be used in any report.
Voluntary participation: Your participation in the study is completely voluntary.
Right to withdraw from the study: You have the right to withdraw from the study at any time without penalty.
How to withdraw from the study: If you want to withdraw from the study, tell the experimenter quietly and leave the room. There is no penalty for withdrawing. You will still get class credit for participating in the study.
Payment: You will receive no payment for this study. You will receive participation credit from your class instructor.
Whom to contact if you have questions about the study: Dr. John Professor, 507 Research Building, Lynchburg College, Lynchburg, VA 24501. Telephone: 434/544-0000. E-mail: Professor@lynchburg.edu
Experimenters: Allison Student (544-0000), Niki Person (544-0000), John Researcher (544-0000).
Whom to contact about your rights in the study: Alisha Marciano, Ph.D., Psychology Department, Lynchburg College, Lynchburg, VA 24501. Telephone: 434/544-8088. E-mail: Marciano.a@lynchburg.edu
Agreement:
I agree to participate in the research study described above.
Signature:_____________________________________ Date:_________