Research Consent Form Sample - Tufts University
Tufts University Institute for Global Leadership
96 Packard Avenue
Medford, MA 02155
USA
CONSENT FORM EXAMPLE # 3
STUDY DETAILS:
•
CONSENT TYPE: ORAL CONSENT WITH SHORT FORM WRITTEN
CONSENT
•
PARTICIPANTS: OVER 18
EXAMPLE ONLY – DO NOT COPY VERBATIM
CONSENT FORMS MUST BE APPLICABLE TO YOUR PARTICULAR
RESEARCH QUESTION AND METHODOLOGY
Oral Consent (to be used in conjunction with short form written consent)
STUDY TITLE: Rural Education in Balan, Haiti
INVESTIGATOR: Valerie Schenkman
BACKGROUND AND PURPOSE: You are being asked to take part in a research project,
which is being organized by RESPE (Research and Engagement Supporting Poverty
Elimination), a group of Tufts University students supported by the Tufts Institute for Global
Leadership. The purpose of this research project is to learn more about the state of Balan’s
education system, its effects on the community as a whole, and in turn what factors in the
community affect its education. My research is contributing to a greater assessment of
where, how, and with whom, Tufts University can mobilize its academic resources in the
possibility of supporting Haitian-led initiatives working to eliminate poverty and its effects in
the community. As a community member of Balan, you are in a position to provide me with
insight into the situation, and I would appreciate it if we could interview you.
PROCEDURES: The format of the interview will be a discussion or perhaps a group
discussion. I expect that the interview will take no longer than 1 hour. With your permission, I
will audiotape the interview solely for the purposes of accurately transcribing the
conversation. With your permission I would also like to take photographs. The audiotapes
and photographs, as well as the transcriptions will be stored securely at the Institute for
Global Leadership in the USA. The photographs will be used to present our research at
various conferences and at Tufts University.
CONFIDENTIALITY AND RISK: There is some risk involved if, for example, you divulge
confidential information. Therefore, if you wish pseudonyms to be used to protect your
privacy and confidentiality, I will be happy to do so. Alternately, if you wish to be quoted by
name on anything in particular I am also happy to accommodate this request. Please know
though that you do not have to answer any questions or discuss any topics that make you
feel uncomfortable.
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