Sample Consent Form (for Adult Participants)
Agreement to Participate in Research
[If you are an SJSU student, please indicate this after
your name or in an introductory statement in item #1]
Title of Protocol:
1. You have been asked to participate in a research study investigating…
[explanation of the purpose of the research].
2. You will be asked to…
[describe what will be required of subjects, where and when the study will occur, and
what materials and/or devices will be employed, including the use of audio/visual recording devices].
[Include a description of any foreseeable risk or discomforts to the subjects, or a statement that no risks are
anticipated. Please be aware that emotional discomfort is considered to be a risk of which subjects must be
[Include a description of any direct benefits to the subjects or to others which may reasonably be expected
from the research, or a statement that no discernable benefits are expected. General feelings of reward from
being of help to research are not direct benefits; however, you may add that these are possible, indirect benefits,
[Alternative procedures (if applicable
if not applicable, omit this item and re-number all subsequent items). ]
6. Although the results of this study may be published, no information that could identify you will be included.
identifying information will be included in publication or dissemination, this statement should be revised. In
certain unusual situations, you may prefer to attach a full “release to publish” statement. Otherwise please
describe the manner in which confidentiality will be maintained. ]
[Compensation for participation in the study (amount, nature, and reason), if any. Otherwise, please state that
there is no compensation for participation.]
8. Questions about this research may be addressed to
[name of the responsible investigator, area code, and phone
number; or email address].
Complaints about the research may be presented to
[name of the respective department
Chair (or of the respective College Dean, if there is no department Chair), title, department/college, area code and
Questions about a research subjects’ rights, or research-related injury may be presented to Pamela
Stacks, Ph.D., Associate Vice President, Graduate Studies and Research, at (408) 924-2427.
9. No service of any kind, to which you are otherwise entitled, will be lost or jeopardized if you choose not to participate in
10. Your consent is being given voluntarily. You may refuse to participate in the entire study or in any part of the study.
you are doing surveys or interviews, add the statement: You have the right to not answer questions you do not
wish to answer.]
If you decide to participate in the study, you are free to withdraw at any time without any negative effect