Sample Consent

Minimum Information that should be included in a consent form:

  • explanation of purposes of research
  • expected duration of subject’s participation
  • description of procedures
  • identification of any procedures that are experimental
  • description of any foreseeable risks or discomforts
  • description of steps taken to ensure confidentiality
  • explanation of whom to contact for answers to any questions
  • statement that participation is voluntary, that subjects can withdraw without penalty at any time

Note, items in brackets are parenthetical explanations of what should go in the preceding blank. Do not leave bracketed items in your final consent form.

Consent Form

Complete Title of Research Project


You, _____________, have been asked to be in this research study, which has been explained to you by _____________ . This study is being conducted by _____________ [list all investigators – full names and degrees] in the Department of _____________ at _____________[Kalamazoo College] with funding provided by _____________ [if appropriate] or sponsored by _____________ [if appropriate].

[For SIPS:]
This research is being conducted to fulfill the degree requirements for Bachelor of Arts at Kalamazoo College, under the supervision of Dr. _____________ [provide name and degrees of your faculty advisor].

Purposes of the Study

The purpose of this study is to learn more about _____________ .

Description of Procedures

This study involves _____________ [describe procedures in appropriate detail; e.g. answering questions about your music preferences] and will take approximately _____________ [state how long it will take to participate in the study] for you to complete.

You will be asked to fill out a questionnaire regarding _____________ [state what the questionnaire is about]. This will take approximately _____________ [state how long it will take to complete the questionnaire]. You do not have to answer all the questions. You will have the opportunity to see the questionnaire before signing this consent form.

Risks and Discomforts

There are no known or expected risks for participating in this study, except for the mild frustration associated with answering the questions. You may decide at any time to quit the study.


You may not receive any direct benefit from this study. The knowledge gained from this study may eventually benefit others.

Financial Considerations

No payments will be made for participating in this study.


Any information about you that is obtained as a result of your participating in this research will be kept as confidential as legally possible. Your research records and test results, just like hospital records, may be subpoenaed by court order or may be inspected by federal regulatory authorities without your additional consent.

In addition, there are certain instances where the researcher is legally required to give information to appropriate authorities. These would include mandatory reporting of infectious diseases, mandatory reporting of information about behavior that is imminently dangerous to you or to others, such as suicide, child abuse, etc.

Audiotapes or videotapes will be kept locked and will be destroyed as soon as possible after the research is finished.

In any publications that result from this research, neither your name nor any information from which you might be identified will be published without your consent.

Voluntary Participation

Participating in this study is voluntary. You are free to withdraw your consent to participate in this study at any time.

Refusal to participate or withdrawal will not affect [your class standing, grades, etc. as appropriate] and will involve no penalty to you.

You have been given the opportunity to ask questions about the research, and you have received answers concerning areas you did not understand.

I willingly consent to participate in this research.

_________________________ Signature of Subject
_________________________ Printed Name
Date _____________ Time___________

_________________________ Signature of Investigator
_________________________ Printed Name
Date _____________ Time___________

Contact Persons
Form more information about this research, you may contact _____________ at _____________ . This research has been approved by the Institutional Review Board of Kalamazoo College for research with human subjects.

Printable Version

Would you like a printable version? Feel free to download a printable version of this Sample Consent Form (Word Doc 16KB).

Microsoft Word

Please note that this document is in Word format. Don’t have Word on your computer or laptop? Not to worry! All K College students, faculty, and staff may use their Office 365 accounts to edit this document. For further information visit the Information Services page on Office 365.