Human Subjects Committee
IUN Exhibit A
Below is a sample of Students as Subjects Consent Statement.
Collection of Data by Third Person
SAMPLE CONSENT FORM
Indiana University Northwest
Informed Consent Statement
[Project Title] Study #______
Dear [name of course] Students:
You are invited to participate in a research study which aims at improving the learning of [subject]. As you already know, the goal of [name of course or course number] is to [purpose of class]. Whereas the curriculum employed in this course has been successful in general during the last few years, we are always looking for ways to improve the course, and make itmore in accordance with current trends in education. We are in theprocess of modifying the _____ class to introduce new teaching strategies. While making these changes, we would also like to measure their effectivenessby comparing data from students in classes that are now being modified withdata from students in classes that have not yet been changed. In thisway we can determine whether the changes are effective, and whether additional changes will also be necessary.
The study will be conducted within the context of your regularly scheduled class sessions. Your participation should require no additional out of class time. At the beginning of the semester you will be asked to take a short 12 item test on ____________. Other data used in the study will come from the multiple choice portion of your final exam which willnot be modified in any way for use in the research. An instructor other than your instructor will distribute and collect this consent form and the pretest, so that your instructor will not know if you have participated until after the course if finished and grades entered.
Confidentiality of participants will be protected by destroying all dataonce it has been analyzed. All identifiers will be removed and no reference will be made to individual students in oral or written reports which could link you to the study.
Your participation in this study is voluntary. If you decide not to participate, the scores obtained on your tests will be used for your course grade but will not be used for the study. There will be no penaltyfor not participating. If you decide to participate, you may withdrawfrom the study at any time. After completion of the study, I will behappy to discuss the results with you. Should you have any questionswhile the study is in progress, or should you decide any time to withdraw,please contact the person who is collecting this consent form ____________by email ( email@example.com) or by calling____________. After the study is over and your grade had been postedI will be willing to answer any questions, or withdraw your data, if youwish.
If you are willing to participate in the study, please sign one of the two copies of this letter and return it to the _________. The second copy is for you to keep for reference. If you feel you have not been treated according to the descriptions in this form, or that your rights as a participant have not been honored during the course of this project, you may contactthe Human Subjects Committee, Academic Affairs, Indiana University Northwest, Gary IN 47405, 219 980-6707, or email at firstname.lastname@example.org.
We appreciate your considering to participate in this research and thus enabling us to improve instruction in the ________ course.
[name of instructor/researcher]
I have read and understand the above described information and have received a copy of this form. I agree to take part in the study.
Subject's signature ____________________ Date_________
Consent form date XX-XX-XX