Sample Script For Verbal Consent printable pdf download

SAMPLE SCRIPT TO BE USED BY STUDENTS FOR VERBAL CONSENT

You must modify this script so that it is applicable to your course situation.)

(

All the information contained in the script must be transmitted to the participant although it need not be

reproduced verbatim.

At the conclusion of the interview the student must sign the script, indicating that the participant has been fully

informed and given consent to be interviewed. This form may be used by one student for multiple interviews

provided the student signs and documents the date of each interview. The student should then retain for him/herself

a list of interviewees and corresponding dates. Instructors should retain the signed form for at least five years.)

Each student conducting an interview must hand in the script that they have used followed by their

signature indicating that all the information has been given.

Example of script to be used by students to obtain informed consent. Please modify to suit your own course.

Title of course and instructor’s name

(example: Advanced Leadership 492. Dr. Jane Smith)

My name is John Q. Student, and I am a student in the Advanced Leadership 492 course given by Dr. Jane

Smith at Trinity Western University. I am taking the course to learn more about leadership effectiveness. As

you are recognized in your field as an effective leader, I would like to ask you what accounts for your success

and how you became an effective leader. I expect to need approximately one half hour of your time. If you

agree to participate, the information you give me will be used only in anonymous form in class discussion, and

will be treated as confidential beyond the class briefings and discussion. Notes from the interview will be kept

in a locked cabinet and destroyed at the completion of the study. Any details which might identify you will not

be shared with the class or other individuals. You should feel free not to provide any information you do not

wish to share with me or to end the interview at any time. If you wish to end the interview early, any

information you have provided up to that point will be included in the study data unless you ask me not to

include it. Do you have any questions about the purpose or the process? Is there anything else you would like

me to clarify? If you have any concerns about your treatment or rights as a research participant, you can

contact Sue Funk in the Office of Research at Trinity Western University. Here’s her phone number. (Hand

them a slip of paper with the contact information written on it: Sue Funk, Office of Research, Trinity Western

University, 604-513-2142.)

Example of signature portion of form.

Your signature indicates that you have informed each participant of your role as a student, the nature and

purpose of the interview, the conditions of confidentiality and of their right to end the interview at any time. It

also indicates that you have provided each participant with an opportunity to ask, and have addressed, any

questions they might have about the study.

Student’s Name___________________________________________

Date of Interview______________________ Student’s Signature________________________________

Revised September 2010

Sample Script For Verbal Consent