Consent Form Sample #2 for Participation of Human Subjects in Research*

  1. Purpose:
    The purpose of this research is to study how people remember lists of items. The results are intended to provide insights into memory processes.
  2. Procedure:
    You will be shown some lists of words one word at a time. After a given list has been presented, you will be asked to write down as many of those words as you can remember.
  3. Time required:
    Your participation will involve one session lasting approximately 45 minutes.
  4. Risks:
    It is not anticipated that this study will present any risk to you other than the inconvenience of the time taken to participate.
  5. Your rights as a subject:
    • (i) The information gathered will be recorded in anonymous form. Data or summarized results will not be released in any way that could identify you.
    • (ii) If you want to withdraw from the study at any time, you may do so without penalty. The information collected from you up to that point would be destroyed if you so desire.
    • (iii) At the end of the session, you have the right to a complete explanation ("debriefing") of what this study was all about. If you have questions afterward, please ask your researcher or contact:

      Dr. John Doe (or faculty sponsor's name, for students)
      Dept of Psychology, Iona College, 914-633-xxxx.

      Also, once the study is completed, you may request a summary of the results.

  6. If you have any concerns about your treatment as a subject in this study, please call, email, or write:

Dr. Tresmaine Grimes
Provost's Office
Telephone: 914-633-2602

This research project has been approved by the Iona College Institutional Review Board, Protocol Number       .

I have read the above information and willingly consent to participate in this study. I attest that I am 18 years of age or older.


Participant signature


Participants should be given a copy of this form for their own records.

* This template is adapted from the University of Wisconsin-Superior and the University of Minnesota Institutional Review Board Forms.