Consent Form

Tool for Community Involvement

What

A template that you can use to create a consent form for your project. This template provides sample text and can be adapted for use based on the context of your project and participant needs. You may wish to communicate the content verbally or in another form that works best for your participants.

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Why

It can be helpful to use a template as a starting point in order to customize your own consent form.

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Use this template as a starting point to create a consent form for your project.

Date: [Date]

Project Title: [Project Title]

Principal Investigator:

  • [Name]
  • [Position]
  • [Organization]
  • [Email]
  • [Phone Number]

Research team contact:

  • [Name]
  • [Position]
  • [Organization]
  • [Email]
  • [Phone Number]

What's involved

You are agreeing to participate in a co-design workshop that will take approximately [duration] to complete. You can take a break at any time and we will proceed once you are ready to continue. Please read through the following information and if you agree to participate in the [Activity Name] accept the consent statement at the end of this document. If you decide to decline the consent form, we will not be able to conduct the [Activity Name].

Potential benefits and risks

There are no associated risks to participate in [Activity Name] greater than those you might encounter in everyday life. Your participation in [Activity Name] will be considered part of your contribution to [primary goal of the project]. Your feedback also contributes to [secondary goal of the project].

Confidentiality

[Organization] will keep your responses confidential.

Quotes and ideas

You will not be identified individually in any way in written reports of this research unless you consent to your quotes and ideas being attributed to you by selecting the appropriate checkboxes at the bottom of this document. If you agree to being quoted, we will send you a link to the summary report prior to publishing for your final review and approval.

Data files

During the research and analysis period, access to data files will be restricted to the research team. All files will be stored in the [Organization] secure database until [Date], after which all data related to this study will be erased from the [Organization] database.

[If there is a possibility your research could include disclosure of information that may require the researcher to break confidentiality and report details to a third party, include this: “In exceptional and compelling circumstances, we may be subject to obligations to report information to authorities to protect the health, life or safety of a participant or a third party, a community, or the general population.”]

Voluntary participation

Participation in this study is voluntary. If you wish, you may decline to answer any questions. The research results will be disseminated after [Date]. Thus, if you wish to withdraw from this study, or request withdrawal of your data, please send your request by email to [Project contact name] prior to [Date]; and you may do so without any penalty or loss of benefits to which you are entitled.

Publication of results

Results from this study will be published on the [e.g. project public website]. During any such dissemination, data will be presented in aggregate forms. We will not quote any statements made by you without your permission. Quotes will not be attributed to you without your permission. Please provide your consent below if your response may be quoted and if you wish your name to be stated along with any quotes. A link to the summary report will be sent to you via email after it has been published.

Contact information and ethics clearance

If you have any questions about this study or require further information, please contact the Principal Investigator, [Name] or the research team contact, [Contact Name] using the contact information provided above. This study has received ethics clearance through the Research Ethics Board at Organization [No. xxx]. If you have any comments or concerns, please email the Research Ethics Office through [Contact email].

I agree to participate in the study described above. I have made this decision based on the information provided in this Consent Letter. I have had the opportunity to request and receive any additional information and understand that I may ask questions in the future. I understand that I may withdraw my consent at any time. Checking the relevant boxes below indicates my consent for those activities.

If you wish to participate in the [Activity Name], please check the appropriate consent boxes below and return this form to [Contact Email].

❏ I have read and understood the above information. I certify that I am 18 years or older. I consent to participate in this study.

Please select one of the following options for your quotes:

❏ I do not want my responses quoted directly.

❏ My responses may be quoted anonymously.

❏ My responses may be quoted and should be attributed to me (your name will appear with the quoted material).

Please select one of the following options for your ideas:

❏ I do not want my ideas attributed to me.

❏ My ideas should be attributed to me (your name will appear with the idea description and any associated images).

Thank you for your assistance in this project.

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Consent and Ownership Agreements

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