UNIVERSITY
OF MASSACHUSETTS LOWELL
Date
Prepared/Revised: ____________________
Project Title:
________________________________________________________________________
________________________________________________________________________
Researcher(s):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
APPROVED FOR USE BY THE
UNIVERSITY OF MASSACHUSETTS LOWELL INSTITUTIONAL REVIEW BOARD.
This Informed
Consent Form is valid for a period not to exceed one year from the date
of the approval appearing above.
Purpose
You are being asked to participate in a research
study that…
Procedure
and Duration
You are being to asked to …
Risks
and Discomfort
There are no significant risks involved in being a
participant in this study…
Benefits
If you are enrolled in General Psychology, you may
earn one research credit by participating in this study. There are no other benefits.
Refusal
or Withdrawal of Participation
Participation in this study is completely
voluntary, and your participation or non-participation will not affect other
relationships (e.g., the University, Psychology Department, the faculty, or the
students). You may discontinue your
participation in this research program at any time without penalty or costs of
any nature, character and kind.
Privacy
and Confidentiality
Every
precaution shall be taken to protect your privacy and the confidentiality of
the records and data pertaining to you in particular and the research program
in general, disclosure of which may contribute to identifying you specifically
to persons not related to this research program. Examples of precautions to be taken would be: destruction of raw data, removal of
identifiers linking subject to data, etc.
Audio/video tapes will be destroyed at the end of three years.
Additional
Information
If
you do not understand any portion of what you are being asked to do or the
contents of this form, the researchers are available to provide a complete
explanation. Questions relating to this
research project are welcome at any time.
Please direct them to ….., the Researcher(s), or Dr. Doreen
Arcus, the Faculty Advisor, at the following addresses/telephone numbers:
Sally Jones Dr. Doreen
Arcus
c/o Psychology Department Dept. of Psychology
Mahoney Hall, Room 110 Mahoney Hall, Room 8
University of Massachusetts
Lowell University of Massachusetts
Lowell
978-934-3950 Lowell, MA 01854
978-9344172
________________________________
________________________________
________________________________ ____________________________________
Researcher(s) Date Faculty Advisor (if applicable) Date
[Every individual listed as a
Researcher must sign this form.]
I
have been informed of any and all possible risks or discomfort.
I have read the statements contained herein,
have had the opportunity to fully discuss my concerns and questions, and fully understand
the nature and character of my involvement in this research program as a
participant and the attendant risks and consequences.
Research
Participant Date