Project Title:

Principal Researcher(s):

Description of purposes and explanation of procedures (provided by the researcher in oral or written form to the interviewee):

1. A statement that the study involves research.
2. An explanation of the purposes of the research.
3. The expected duration of the subject's participation.
4. A description of the procedures (including methodology) to be followed.
5. A description of any reasonably foreseeable risks or discomforts.
6. A description of any benefits to the subject, or to others which may reasonably be expected from the research.
7. A statement describing the extent, if any, to which confidentiality of data and privacy of subject(s) will be maintained.
8. An explanation of whom to contact for answers to pertinent questions about the research, subject's rights, and research related injury to the subject(s).
9. A statement that participation is voluntary.

I acknowledge that__________________________________(principal researcher) has fully explained to me the purposes and procedures, and the risks of this research; he has informed me that I may withdraw from participation at any time without prejudice; and has informed me that I will be given a copy of this consent form. I am over 18 years of age, and I freely and voluntarily consent to my participation in the above mentioned research project.

I waive ______ or do not waive _______the right to anonymity (my name may or may not be used in the research).

List any special stipulations or conditions established by the interviewee in the conduct or disposition of this project on the back.

Signature of Interviewee:

Signature of Principal Researcher:

Date: