PITZER COLLEGE
INFORMED CONSENT FORM TO CONDUCT RESEARCH ON SITE
Faculty Supervisor/Principal Investigator:
Student Investigator(s)/Research Assistant(s):
Title of research project:
I acknowledge that on , I was informed by of Pitzer College about this
research project, the way it will be conducted and the conditions of participation in it.
We at are aware of the nature and extent of the organization’s participation in this
project and agree with full knowledge to allow the subjects to participate. Subjects may
withdraw their participation on this project at any time without prejudice or penalty of any kind.
In the case of minors, parents/guardians will be informed that they may withdraw their child’s
participation on this project at any time without prejudice or penalty of any kind.
On behalf of the institution, I give my consent for the research investigator(s) to utilize this site
to recruit and interview its members/students.
Permission to conduct research is granted beginning (date) ___________________ and ending
(date) ___________________.
Name (print): ________________________________________ Date: ____________________
Signature: ____________________________________________________________________
Title: ________________________________________________________________________
Name of the institution: _________________________________________________________
Address: _____________________________________________________________________
Phone number: ______________________ Email: ___________________________________
The institution’s representative should sign two copies of this form. Keep one copy and return
the other copy to the investigator.
Print Form
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signature
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