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Consent Form

Institution:  University of Mount Saint Vincent 


You are invited to consider participating in a research study. The study is called (title). You were selected as a possible participant in this study because you are a (place information here) who is participating in (place information here).

Please take your time to make your decision.  It is important that you read and understand several general principles that apply to all who take part in our studies:

  1. Taking part in the study is entirely voluntary.
  2. Personal benefit to you may or may not result from taking part in the study, but knowledge gained from your participation may benefit others.
  3. You may decide not to participate in the study or you may decide to stop participating in the study at any time without repercussions.

The purpose and nature of the study, possible benefits, risks, and discomforts, other options, your rights as a participant, and other information about the study are discussed below. Any new information discovered which might affect your decision to participate or remain in the study will be provided to you.  You are urged to ask any questions you have about this study with members of the research team.  The decision to participate or not to participate is yours.  If you decide to participate, please sign and date where indicated at the end of this form.

The study will take place at University of Mount Saint Vincent where the researchers are a member of the (place information here) faculty.

Why Is the Study Being Done?
Place information here regarding the rationale for the study. The aim of this research study is to (place information here).

How Many People Will Take Part in the Study? 

Consent Form pp. 1 of 2

(place information here)

What Is Involved in the Study? 

(place information here)

How Long Will I be in the Study?
You will be in the study for (place information here).  You can stop participating at any time. However, if you decide to stop participating in the study, we encourage you to talk to the researcher.

Your refusal or discontinuation to participate will not affect your status at the college and is without repercussions to you.

What Are the Risks of the Study?
It is highly unlikely that you will experience psychological discomfort as a result of participating in this study. The researcher will encourage you to contact the college’s counseling center if you should experience a problem.

Founders Hall 333A
Office hours: Monday – Friday 8:30 a.m. to 4:30 p.m.
(718) 405-3332

Are there Any Benefits to Taking Part in the Study?
We cannot and do not guarantee that you will receive any benefits from this study. You may or may not receive any direct benefit from this study. However, the results of this study may benefit others by providing (place information here).

What Other Options Are There? 

Consent Form pp. 1 of 3

Instead of being in this study, you can choose not to participate.

What About Confidentiality?
Efforts will be made to protect your personal information to the extent allowed by law. Records of research study participants are stored and kept according to legal requirements and then destroyed. You will not be identified personally in any reports or publications resulting from this study. If a report of this study is published, or the results are presented at a professional conference, only group results will be stated. Organizations that may request to inspect and/or copy your research for quality assurance and data analysis include groups such as:  College of Mount Saint Institutional Review Board (IRB) and all appropriate federal research oversight agencies.

If information about your participation in this study is stored in a computer, we will take the following precautions to protect it from unauthorized disclosure, tampering, or damage: Your responses to the questionnaires you will complete will be numerically coded and will be linked to a master list that links your code to your identity. Some of the information collected includes age, marital status, education, occupation and income. All information will be kept confidential by limiting individual’s access to the research data and keeping it in a locked file cabinet located in the PI’s office and on a password protected computer.

The researcher will maintain a list of names of the research subjects and their corresponding code numbers in a password protected computer and flash drive. The researcher will only have access to the password. The research instruments will be labeled with a code number and not your name. The data will be coded and entered into a password protected computer. The researcher will only have access to the locked file cabinet.

What are the costs?
There will be no additional cost to you for participation in this study.

Compensation for Participation
You will not receive compensation for participating in this study. (place information here). If extra credit is given the amount is at the discretion of the faculty.

What are my rights as a participant?
Taking part in this study is voluntary. You may choose to not take part in the study or to leave the study at any time. If you choose to not participate in the study or to leave the study, your status Mount Saint Vincent College will not be affected. (This can be modified if a PI is recruiting nurses at a hospital in which “subjects position at the hospital will not be affected”)

Whom do I call if I have questions of problems?
For questions about the study or a research-related injury, any problems, unexpected physical or psychological discomforts, or if you think that something unusual or unexpected is happening, you may

Consent Form pp. 1 of 3

(Place Information Here)

If your participation in this study has in any way upset you, please feel free to set up an appointment with the counseling center. The counseling services can be reached at:

Founders Hall 333A
Office hours: Monday – Friday 8:30 a.m. to 4:30 p.m.
(718) 405-3332 

Researcher’s Statement
I have fully explained this study to you.  As a representative of this study, I have explained the purpose, the procedures, the benefits and risks that are involved in this research study. Any questions that have been raised have been answered to your satisfaction.

Signature of person obtaining the consent              Print Name of Person                               Date / Time

(Principal Investigator or Co-investigator)

Subject’s statement
I, the undersigned, have been informed about this study’s purpose, procedures, possible benefits and risks, and I have received a copy of this consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to participate in this study. I am free to withdraw from the study at any time without need to justify my decision. This withdrawal will not in any way affect my status at the University of Mount Saint Vincent.

Signature of Subject                                                     Print Name of Subject                               Date / Time

Debriefing Form

The purpose of this study is to (State purpose here). Thank you for participating. If your participation in this study has in any way upset you, please feel free to set up an appointment with the counseling center. The counseling services can be reached at:

Founders Hall 333A
Office hours: Monday – Friday 8:30 a.m. to 4:30 p.m.
(718) 405-3332

If you have any questions or concerns about your rights as a research participant please contact the principal investigators PI Name at Number (email) or Name at Number (email)

Signature: ______________________________


Date:  ________________________