Informed Consent Example

You are invited to participate in a survey to gather feedback from educators, healthcare and human service providers, and community leaders to identify the needs of elders in our communities.  Additionally, this survey aims to identify the educational needs of healthcare and human service providers who care for the aged in our communities.  The information obtained from this survey will be utilized to identify the needs of the elders in our community to foster the development of curriculum relevant to a multidisciplinary “Aging” certificate program of study at Lewis-Clark State College.

Your participation in this survey is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. Your survey responses will be strictly anonymous and data from this research will be reported with no identifying information.  Once you complete the survey and submit it, anonymous data will be forwarded to the evaluators.

This survey should take approximately 10 minutes to complete. Please complete each question to the best of your ability. If you have any questions or require assistance to complete this survey please feel free to contact (NOTE: your name and contact information go here. Use your lcwarriormail address and your agency phone number).  By taking the time to complete and submit the survey, you are acknowledging acceptance of the informed consent provided. 

If you have any questions regarding this study feel free to contact Dr. Brian L. Christenson at (208) 792-2476; blchristenson@lcsc.edu, or the Institutional Review Board of Lewis-Clark State College at (208) 792-2461.  Thank you very much for your time and support. If you acknowledge this informed consent and decide to participate, you may start below by checking the appropriate box.  Please answer the questions to the best of your ability.

NOTE: Please feel free to copy this document and modify it to your study.

Dr. Christenson