Consent Form Sample:
This is a sample consent form: informed consent should be designed and presented in such a way that
facilitates a potential subject’s understanding of why one would want to participate in a research study or
not, and explain the risks and benefits in participation if any. You may use your own template or edit this
version. Please submit the final copy of exactly what your subjects will see and or sign. Be sure all
procedures involving the participants are listed specifically. Include photographing, recording, filling out
surveys, submitting materials, interviewing, etc. (see sample form)
Note: You may need to remove or add information based on your research.
HUMAN SUBJECTS CONSENT FORM
The following is a brief summary of the project in which you are asked to participate. Please read
this information before signing the statement below. You must be of legal age or must be co-
signed by parent or guardian to participate in this study.
TITLE OF PROJECT: An exploration of personality characteristics and mood state.
PURPOSE OF STUDY/PROJECT: To determine the relationship, if any, between
socialized personality characteristics and mood state
SUBJECTS: Psychology freshman level students
PROCEDURE: (Give a step by step Process of what the participants will asked to
do) You voluntarily complete a packet of self-report inventories, including a sex role
questionnaire, a depression inventory, and a self-efficacy survey. This will take
approximately 20 minutes. Data will then be analyzed to determine the relationship
among these variables. All information will be kept strictly confidential, with no way to
identify the participant. Individual results will not be shared.
BENEFITS/COMPENSATION: By participating in this study, we can gain better
knowledge in the relationship of socialized personality characteristics and mood, which
in turn may help gain a better understanding in social diseases.
RISKS, DISCOMFORTS, ALTERNATIVE TREATMENTS: There are no risks
associated to this study, but some questions may be personal in nature. You may skip
any questions that may make you feel uncomfortable.
The participant understands that Louisiana Tech is not able to offer financial compensation nor to
absorb the costs of medical treatment should you be injured as a result of participating in this
The following disclosure applies to all participants using online survey tools: This server may
collect information and your IP address indirectly and automatically via “cookies”.
I, ___________________, attest with my signature that I have read and understood the
following description of the study, “(An exploration of personality characteristics and mood state)",
and its purposes and methods. I understand that my participation in this research is strictly
voluntary and my participation or refusal to participate in this study will not affect my relationship
with Louisiana Tech University or my grades in any way. Further, I understand that I may
withdraw at any time or refuse to answer any questions without penalty. Upon completion of the
study, I understand that the results will be freely available to me upon request. I understand that
the results of my survey will be confidential, accessible only to the principal investigators, myself,
or a legally appointed representative. I have not been requested to waive nor do I waive any of my
rights related to participating in this study.