Andrews University
Behavioral Science Department
Consent Form

Title of study: [Title Goes Here]
[Principle Investigator Names]
Behavioral Science Department, 123 Nethery Hall, Andrews University 
Berrien Springs, MI 49104-0030
[investigator email address]

Research Supervisor:
Dr. Karl Bailey
Behavioral Science Department, 123 Nethery Hall, Andrews University 
Berrien Springs, MI 49104-0030
kgbailey@andrews.edu
(269) 471-3577

Purpose:
	[why are you doing this experiment? talk about the general field, not your research question itself]

Inclusion Criteria:
	I have been told that for me to participate in this study I must be [inclusion criteria go here].

Procedure:
	I have been told that I will be asked to [describe procedure here – this may require multiple sentences].

Risks and Discomforts:
	[sample follows] I have been told that there are no known risks for participating in this study. I have been told that data recorded during this experiment will be assigned a random number that will never be associated with my name or other identifying information during analysis. I have been told that the data collected from this experiment will be analyzed a group, rather than individual, data.

Benefits and Results:
	[sample follows] I understand that I may not receive any direct benefits from participating in this study.  I understand that the results may help cognitive psychologists to better understand [the topic of your study].  I understand that the information collected during this study may be presented or published in professional meetings or journals, or as part of undergraduate research forums on campus.

Voluntary Participation:
	I have been told that my participation in this study is voluntary.  I have been told that I may discontinue my participation in this study at any time without any penalty or prejudice.  I also have been told that there is no compensation  in return for my participation.

I have been told that I may contact the researcher, [your name], at [email or phone], investigator’s research supervisor, Dr. Karl Bailey, at (269)-471-3577 or kgbailey@andrews.edu. I have been told that if I wish to contact an impartial third party, I may contact the Chair of the Behavioral Sciences Department at 471-3152 for information and assistance.

I have read the contents of this consent form and have listened to the verbal explanation given by the investigator. My questions have been answered to my satisfaction. I hereby give voluntary consent to participate in this study. If I have additional questions or concerns, I may contact [your name] using the information above. I have also been given a copy of this consent form.

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Signature of Subject						Date

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Print Name						

I have reviewed the contents of this form with the person signing above. I have explained the potential risks and benefits of the study.

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Signature of Investigator			Phone Number	Date