Sample Consent Forms
Individual Interviews
What Is This Study About?
You are invited to participate in a research study entitled _____________________________.
The purpose of the study is to identify gaps and barriers in services available to crime victims
with disabilities in our community. You are being asked to participate because (a) you are a
person with a disability, (b) you are a disability service provider, (c) you are a victim service
provider, (d) you work in law enforcement, or (e) other
_________________________________________.
The study is being conducted by ________________________________________________
__________________________________________________________________________
(name of project coordinator, agency name, address, phone number).
What Will I Be Asked To Do?
You will be asked to answer questions about services for crime victims with disabilities in our
community, either from your personal or professional experience. Someone from our staff will
take notes, but we will not attach your name to the notes. We estimate that it will take about 1
hour for you to answer the questions. You will only need to participate in one interview.
If you request, a professional, certified American Sign Language or Spanish interpreter will be
used in this study. As a professional, this interpreter is required to keep confidential your name
and any information discussed in the session. This interpreter works for ____________________
(agency).
What Are the Risks and Benefits of My Participation?
You may become emotionally distressed when talking about your experiences. If you become
distressed, you may stop or end the interview at any time. A trained service provider or advocate
will be available to talk to you during or after the interview. In addition, we will provide written
information about community resources for counseling and support.
Even though this project will not help you directly, the results may help ____________________
(subrecipient) and its community partners improve services for future victims of crime with
disabilities. Your decision whether or not to participate in this study will not affect any services
you currently receive or will in the future receive through _______________________ (agency
name).
Are There Any Costs?
There are no costs for participating.
Will I Be Paid?
You will receive _______________________ (describe reimbursement; where there is none,
state as such) for your participation.
Your Rights and Confidentiality
If you agree to participate in this study, please understand that your participation is voluntary
(you do not have to do it). You have the right to withdraw your consent or stop your participation
at any time without penalty. You have the right to refuse to answer particular questions or to
decline any procedure. You may leave the meeting at any time.
Notes about what you say will be taken during your interview, but they will not include your
name or any information that could identify you to others.
Every effort will be taken to protect the identity of the participants in the study. You will not be
identified in any report or publication of this study or its results. However, there is no guarantee
that the information cannot be obtained by legal process or court order.
Finally, you should understand that if you reveal that there is a current danger to yourself or to
others, the person interviewing you may need to report that danger to authorities.
In group activities, you do not need to reveal your name. You may use a fictitious name if you
wish. You must agree not to reveal anything you learn about other subjects from group
discussions or other activities.
If you change your mind and do not want to be interviewed, contact ______________________.
The extra copy of this consent form is for you to keep.
Agreement Statements
I have read and understand the information presented here, and I freely give my consent to
participate in this research.
Verbal Consent
Do you have any questions before we begin? _____________________________________
__________________________________________________________________________
__________________________________________________________________________
Is it okay to continue with the interview?
Verbal consent given: ___Yes ___No
_________________________________________ _________________
Signature of Interviewer Obtaining Verbal Consent Date
Written Consent
_________________________________________ _________________
Signature of Research Subject Date
_________________________________________
Printed Name of Research Subject
_________________________________________ _________________
Signature of Interviewer Obtaining Consent Date
_________________________________________
Printed Name of Interviewer Obtaining Consent