Informed Consent
for Dr. Jane Doe
201-555-1212A. This section describes the purpose of the study the research procedures in which the subjects may be involved the duration of involvement [attached is the questionnaire if one is being used].B. This section describes the potential risk of discomfort and if any potential benefits [physical psychological social legal or other] that may be reasonably expected by participating in this research.C. This section describes the procedures that will be used to minimize risk to obtain informed consent and to protect the data and maintain confidentiality.I ___________________________________ [full name] have read and understand the conditions and risks above and I consent to voluntarily participate in this research study. I realize I am free to withdraw my consent and to withdraw from this study at any time without negative consequences.________________________________________ [signature] ______________[date]
[Reference: Publication Manual of the American Psychological Association 5th ed.]

Attachments: