Informed Consent to Participate in a Research Study
Title of Research:
Name of Principal Investigator/Primary Researcher:
A. PURPOSE AND BACKGROUND
Under the supervision of Dr. (insert faculty memberís name), Professor of (insert Department name) at San Francisco State University, (insert your whole name) a graduate student in research (insert Department name) is conducting research on (insert what the research is about.) The purpose of this interview is to help the researcher study (insert why you are doing this research.)
If I agree to participate in this research study, the following will occur: (The following is sample information, do not copy it, instead insert what is appropriate for your research.)
1. I will be asked to participate in an individual interview (indicate the amount of time it will take to participate in the interview.)2. I will be asked to discuss the following topics:a. stress in my lifeb. ways I deal with stressc. support systemsd. personal resources for coping
3. I will also be asked my age, gender, race, sexual orientation, socio-economic status, and educational background.
4. If I agree to participate in this research study, an audio tape of this interview will be made for research purposes.
I will be asked questions of a personal nature and I might feel uncomfortable talking about some things. I am free to decline to answer any questions that I donít wish to answer, or I may stop my participation in the discussion at any time without penalty.
If there are no risks state the following:There are no known foreseeable risks or discomforts involved in participating in this study.
The records from this study will be kept as confidential as possible. No individual identities will be used in any reports or publications resulting from the study. All tapes, transcripts and summaries will be given codes and stored separately from any names or other direct identification of participants. Research information will be kept in locked files at all times. Only research personnel will have access to the files and the audio tapes and only those with an essential need to see names will have access to that particular file. After the study is completed and all data has been transcribed from the tapes, the tapes will be held for one year and then destroyed.
(Please note that all informed consent forms must have an explanation of the procedures by which the participantís confidentiality will be protected.)
(Please note: Title of research, and name of Principal Investigator/Primary Researcher must be on each page of an informed consent form no matter the length of the informed consent form. Also, the informed consent must contain sequential page numbers.)
There will be no direct benefit to me from participating in this research study (Note: if the preceding is true of your research, you may copy the aforementioned statement.) Theanticipated benefit of these procedures is a better understanding of what stress African American women who are HIV positive or have AIDS experience and how they cope with this stress.
Please note that direct benefits include free medical care, payment, etc. They do not include adding to a body of knowledge or any potential altruistic benefit.
I am free to choose not to participate in this research study.
There will be no costs to me as a result of taking part in this research study.
I will be compensated $20.00 cash upon completion of this interview.
I have spoken with (insert your whole name) about this study and have had my questions answered. If I have any further questions about the study, I can contact Dr. (insert faculty memberís name), or (insert your whole name) by calling (insert Department phone number with area code) or write to them at the (insert Department name), San Francisco State University, 1600 Holloway Avenue, San Francisco, CA94132
I. CONSENT
I have been given a copy of this consent form to keep.