VASSAR COLLEGE
Department of [Insert name] Consent Form


(Form 1: omit this label)
Primary Investigator: [Insert the name of the professor/supervisor]

Student Researcher(s):

Title of Project: [Insert title of project]

I acknowledge that on ________, I was informed by [insert the name of the professor or administrator] of Vassar College of a research project having to do with the following:

In this section, please:
  1. overview the nature of the research project;
  2. overview the basic procedures/types of questions and the participant's role;
  3. explain how confidentiality will be maintained;
  4. describe the approximate duration of participation;
  5. provide contact information (e.g., e-mail and phone number of the primary investigator) and state that participants may contact the PI with questions or concerns. ]

Potential Risks: [ describe any potential risks and the level of risk]


[Insert the name of the professor/supervisor]


Potential Benefits: [describe any potential benefits]


I am aware, to the extent specified above, of the nature of my participation in this project and the possible risks involved or arising from it. I understand that I may withdraw my participation in this project at any time without prejudice or penalty of any kind. I hereby agree to participate in the project. (You must be at least 18 years of age to give your consent.)



Date:_______________

_________________________
(Printed name of Participant)

_________________________
(Place: City and State)

_________________________
(Signature of Participant)

___________________________________
(Address: e.g., Residence Hall & Room # )