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Informed Consent Sample

Protocol Number:

Project Title:

Researcher: [include name, affiliation and email address]

1. Purpose:

[A sentence describing the study.]

You must be 18 years of age or older to participate in this study. Your signature on this form will provide your confirmation that you are 18 years of age or older.

2. Procedure:

If you volunteer for this research study, you will be asked to [briefly describe what the subject will do in the study].

3. Time Required:

Your participation will involve [how long the study will take].

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 or those encountered in everyday life. It is possible you might feel some discomfort when [what the participant will be doing]. Please be assured that you may skip over any item and/or withdraw from this study at any time and without penalty. If you feel distressed while completing the surveys, please inform the researcher; the debriefing form will provide appropriate contact information for the study supervisor and Provost’s Office as well. If you do experience discomfort and would like to speak to a counselor, you can call the Iona College Counseling Center at (914) 633-2038 or LifeNet, a toll-free crisis line, at 800-543-3638.

5. Your Rights as a Subject:

(i) The information gathered will be recorded in anonymous form. There is no link between your consent form and the data we collect from you. No identifying information will be stored with your data, and summarized results or data 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:

  • The Study Supervisor Contact Info
    [If the PI is a student, include the name, department, college, phone number and email address of the faculty supervisor here.]

A copy of this form is yours to keep. Once the study is completed, you may request to view a summary of the results.

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

Dr. Michael Jordan
Office of the Provost
Telephone: 914-633-2206

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

Authorization: I certify that I am at least 18 years of age and are either a current athlete or a former athlete (competed in the last year). I have read the above and understand the nature of this study and agree to participate. I understand that by agreeing to participate in this study I have not waived any legal or human rights. I also understand that I have the right to refuse to participate and that my right to withdraw from participation at any time during the study will be respected with no coercion or prejudice.

Participant Name (please print)

Participant Signature