Consent Form Generator

Principal Investigator (PI)

Gender:

Male | Female

Name:

Do not use home phone or address if at all avoidable.

University Phone Number (please format, e.g. (212) 998-4808 or +44 (20) 7839 8040):

University/Mailing Address:

Email Address:

NYU School (if applicable):

NYU Department (if applicable):

Institution (if non-NYU):


If you are a student or not a full-time NYU faculty member

Faculty Sponsor Name:

Faculty Sponsor Phone Number (please format, e.g. (212) 998-4808 or +44 (20) 7839 8040):

Faculty Sponsor Email Address:

University/Mailing Address:

Faculty Sponsor School (if applicable):

Faculty Sponsor Department (if applicable):

Faculty Sponsor Institution (if non-NYU):


Research Information

Type of Research:

Doctoral dissertation | Master's thesis

class project | faculty-directed research

Other (please specify, e.g. independent study, undergraduate honors thesis):



Purpose of the Study:

You have been invited to take part in a research study to learn more about

Example 1: the effect of time of day on reading comprehesion.

Example 2: whether people make economic decisions differently when working in a group versus individually.

Example 3: how viewing pictures of natural disasters effects fear of terrorism.



Description of Procedures:

If you agree to be in this study, you will be asked to do the following:

1.
2.
3.
4.
5.

Example 1: Complete a questionnaire about your background (age, gender, education, etc.).

Example 2: Take part in an interview about your responses to two videos showing different hiring techniques for a job as a personnel director.

Example 3: Play three rounds of a computer game that asks you to be an auction buyer in competition with other buyers for a work of art.

If you need more than 5 items, add them manually in your word processing program once the draft has been generated.



Length of Participation (total number & approximate length of sessions):

Participation in this study will take

Example: two hours of your time: 30 minutes to complete the questionnaire and approximately 45 minutes for each of the two interviews. The interviews will be held two weeks apart.



Session Recording (will the subject be audio/video-taped?):

None | Audio | Video



Risks & Assistance Available (is there more than minimal risk, i.e., beyond those of everyday life?):

Yes | No

If Yes, please describe:

Example 1: Although every effort will be made to prevent it, you may find the sensitive nature of some of the questions upsetting. In that event, the investigator will provide you with a referral to a counselor with whom you may discuss your feelings.

Example 2: There is a risk that you may have some muscle soreness for about four days.



Physical Injury (is there more than minimal risk and any possibility of physical injury?):

Yes | No



Fees or Incentives (is there payment, travel reinbursement, gift certificates, etc?):

Yes | No

If Yes, please describe:

Example 1: You will be paid $50 dollars for completing both interview sessions; if you withdraw before the end of the study, no payment will be given.

Example 2: You will receive 1 hour of credit towards your course requirement for completing both surveys; if you withdraw before the end of the study, no credit will be given.

Example 3: You will be paid $30 dollars at the end of each session; if you withdraw before the end of the study, you will keep the payment received for completed sessions.



Methods to Protect Confidentiality:

Confidentiality of your research records will be maintained by

Example 1: assigning code numbers to each participant so that data is never directly linked to individual identity.

Example 2: keeping all completed forms in a locked cabinet only accessible to the investigator.

Example 3: submitting forms with no identifiers to a sealed drop box so that subjects are anonymous.



Minors Involved (< 18 years of age):

Yes | No



Focus Groups or Other Group Activities:

Yes | No



Quotes (will you quote subjects by name?):

Yes | No



Nonparticipation or Withdrawal (only applicable if subjects are student or receive service from a related agency/organization):

Nonparticipation or withdrawal

Example 1: will not affect your services you receive at the NYU Medical Center.

Example 2: will not affect your grades or academic standing.