Example Interview Consent Form with Description
This document describes an example of a Research Consent Form. Key elements of the consent form
are described within square brackets in blue italicized text.
[Include the VIU Logo]
[Project Title] Factors Associated With Academic Success
[Contact information of the Principal investigator and supervisor]
Principal Investigator Student Supervisor
Slade Grade, Student Lloyd Freud, PhD.
Master of Education Department of Psychology
Vancouver Island University Vancouver Island University
Slade.Grade@gmail.com Lloyd.Freud@viu.ca
[Purpose - Explain the topic being explored and why the research is being done]
I am a student in the Master of Education in Educational Leadership at Vancouver Island University
(VIU). My research, entitled “Factors Associated with Academic Success,” aims to identify factors that
determine academic success among students in VIU’s Bachelor of Education program. My hope is that
my research will contribute to the future success of Education students at VIU.
[Description – Describe what the participant is being asked to do, and how much time participation
would take].
Research participants are asked to complete a face-to-face research interview. If you agree, you would
be asked questions concerning your personal experiences while attending VIU, with emphasis on factors
such as social support, financial situation, family responsibilities, and past academic performance. With
your permission, the interview would be audio recorded. Your participation would require
approximately 30 minutes of your time. You have the option of participating anonymously.
[Risk of harm to participants – Describe potential risks of harm participants, such as stress,
embarrassment, loss of privacy, loss of status, and loss of reputation, etc.]
The information collected during the interview is likely to be uncontroversial, and thus the research
poses only a very small risk of harm to participants. Depending on the information you provide, and
whether you choose to participate anonymously, there is a possibility that the information you provide
might cause loss of social status and/or embarrassment.
[Management of Research Information/Data – Describe how you will manage the research data, such
as methods of storage, processing, and whether (and how and when) data will be destroyed after
project completion]
If you choose to participate anonymously, all records or your participation would be confidential. Only
my supervisor and I will have access to information in which you are identified. With your permission,
the interview would be audio recorded and later transcribed into writing. At your request, you will be
provided a copy of the transcript and invited to make changes to the transcript as you wish (e.g. if you
would like withdraw a particular statement you made during an interview). Electronic data will be stored
on a password-protected computer. Signed consent forms and paper copies of interview transcripts will
be stored in a locked file cabinet in my home. Data will be deleted and shredded at the end of the
project, approximately May 31st, 2019.
[Use of Research Information – Describe how the information collected from participants will be used]
The results of this study will be published in my Masters thesis, and may also be used for conference
publications, presentations, and published in peer-reviewed journals.
[Participation and withdrawal – participants must be told explicitly that they have the right to decline
to participate. In accordance with the principal of ongoing consent, participant also have the right to
withdraw from a study at any time where practicable. If you wish to put a limit on the time by which
participants may withdraw, you need to clearly state this in the consent form].
Your participation is completely voluntary. You may withdraw from the study at any time where
practicable, for any reason, and without explanation. If you would like to review and potentially make
changes to the transcript of the interview, you may withdraw up to two weeks from the time of being
provided a copy of the transcript. If you decline to review the transcript, you may withdraw up to two
weeks from the date of our interview. If you choose to withdraw from the study, all information you
provided during the interview would be withdrawn from the study and destroyed.
[Consent and Conditions of Consent]
I have read and understand the information provided above, and hereby consent to participate in this research
under the following conditions:
I consent to the interview being audio recorded. Yes No
I consent to having my personal identity disclosed in the products of the Yes No
research.
I consent to being quoted in the products of the research. Yes No
Participant Name ________________________ Participant Signature ____________________________
[Commitment of Principal Investigator – A commitment of the researcher to adhere to the protocol
described in the consent form]
I, Slade Grade, promise to adhere to the procedures described in this consent form.
Principal Investigator Signature __________________________ Date _______________
[Concerns about your Treatment in the Research]
If you have any concerns about your treatment as a research participant in this study, please contact the
VIU Research Ethics Board by telephone at 250-740-6631 or by email at reb@viu.ca.
Participants should be provided a copy of the signed consent form.
