Human Subjects Institutional Review Board (HSIRB)

Anonymous survey consent - sample

You are invited to participate in a research project entitled "(title)" designed to analyze the sexual attitudes of college freshmen. The study is being conducted by (principal investigator) and (student investigator) from Western Michigan University, Department of _________________. This research is being conducted as part of the (thesis/dissertation) requirements for (student investigator).

This survey is comprised of 25 multiple choice and true/false questions and will take approximately 10 minutes to complete. Your replies will be completely anonymous, so do not put your name anywhere on the form. You may choose to not answer any question and simply leave it blank. If you choose to not participate in this survey, you may either return the blank survey or you may discard it in the box provided. Returning the survey indicates your consent for use of the answers you supply. If you have any questions, you may contact (principal investigator) at (phone number), (student investigator) at (phone number), the Human Subjects Institutional Review Board (269-387-8293) or the vice president for research (269-387-8298).

This consent document has been approved for use for one year by the Human Subjects Institutional Review Board as indicated by the stamped date and signature of the board chair in the upper right corner. You should not participate in this project if the stamped date is more than one year old.

Questions? E-mail the research compliance coordinator.

Office of the Vice President for Research
Western Michigan University
210 W Walwood Hall
Kalamazoo, MI 49008-5456 USA
(269) 387-8298 | (269) 387-8276 Fax