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        University of Michigan

      National Center for Postsecondary Improvement

        Project 5.3 on Student Learning and Assessment


               Sample Informed Consent Form      



The following is a sample consent form for a research project. It is a research project on faculty life on campus, carried out by the principle investigator (PI) of this project from the fake-named Century University. The interviewor (the investigator) should have the interviewee read this form carefully and ask any questions the interviewee may have. Before the interview can start, the investigator and the interviewee should sign two copies of this form. The interviewee will be given one copy of the signed form.



           Consent for Participation in Interview Research


I volunteer to participate in a research project conducted by Dr. [Name of the Principle Investigator] from Century University . I understand that the project is designed to gather information about academic work of faculty on campus. I will be one of approximately 30 people being interviewed for this research.


1. My participation in this project is voluntary. I understand that I will not be paid for my participation. I may withdraw and discontinue participation at any time without penalty. If I decline to participate or withdraw from the study, no one on my campus will be told.


2. I understand that most interviewees in will find the discussion interesting and thought-provoking. If, however, I feel uncomfortable in any way during the interview session, I have the right to decline to answer any question or to end the interview.


3. Participation involves being interviewed by researchers from Century University. The interview will last approximately 30-45 minutes. Notes will be written during the interview. An audio tape of the interview and subsequent dialogue will be make. If I don't want to be taped, I will not be able to participate in the study.


4. I understand that the researcher will not identify me by name in any reports using information obtained from this interview, and that my confidentiality as a participant in this study will remain secure. Subsequent uses of records and data will be subject to standard data use policies which protect the anonymity of individuals and institutions.


5. Faculty and administrators from my campus will neither be present at the interview nor have access to raw notes or transcripts. This precaution will prevent my individual comments from having any negative repercussions.


6. I understand that this research study has been reviewed and approved by the Institutional Review Board (IRB) for Studies Involving Human Subjects: Behavioral Sciences Committee at the Century University. For research problems or questions regarding subjects, the Institutional Review Board may be contacted through [information of the contact person at IRB office of Century University].


7. I have read and understand the explanation provided to me. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate in this study.


8. I have been given a copy of this consent form.



 ____________________________         ________________________

     My Signature                                                Date


____________________________         ________________________

    My Printed Name                                    Signature of the Investigator

For further information, please contact:


    Dr. [Name of Principle Researcher]

    [Contact Information of PI]


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