SAMPLE CONSENT FORM(Delete the word SAMPLE and the two paragraphs below before sending the Consent Form to your research participants)*NB to Researcher/Supervisor:

1. Design the consent form to suit your research project.2. Please remove any statements below that are not relevant to your

research before submitting for approval or add additional pertinent statements.

3. Check all statements that are asterisked. Remove asterisks and all blue text.4. The consent form should be kept to one page, if possible.5. The Consent Form is given to and retained by the Southern Cross University researcher for

their records. The Information Sheet is kept by the participant. If the participant requests a copy of their consent form, a copy should be provided to them.

Title of research project: ……………………………………..

Name of researcher: …………………………………………

At the end of each statement, tick the box that applies, sign and date the form and return it to the researcher at the address provided.

YES NOI agree to take part in the Southern Cross University research project specified above.I understand the information about my participation in the research project, which has been provided to me by the researchers.I agree to be interviewed by the researcher.* (Or I agree to attend a workshop – or whatever it is that the person is agreeing to).*I agree to allow the interview to be *audio-taped and/or *video-taped.I agree to make myself available for further interview if required*I understand that I can ask for the recording to be paused if I wish to say something ‘off the record’.*I understand that my participation is voluntary and I understand that I can cease my participation at any time.I understand that my participation in this research will be treated with confidentiality and that any information that may identify me will be de-identified at the time of analysis of any data.I understand that no identifying information will be disclosed or published.I understand that all information gathered in this research will be kept safely and securely at Southern Cross University for a minimum of 5 years after publication.I consent to the data (or tissue*) collected in this research being used in future research.I am aware that I can contact the researchers at any time with any queries.

www.scu.edu.au

Lismore Coffs Harbour Gold CoastPO Box 157, Lismore NSW 2480 Australia Hogbin Drive, Coffs Harbour NSW 2450 Australia Locked Mail Bag 4, Coolangatta QLD 4225 AustraliaT +61 2 6620 3000 F +61 2 6620 3700 T +61 2 6659 3777 T +61 7 5589 3000 F +61 7 5589 3700

CRICOS Provider 01241G

Their contact details have been provided to me.I understand that this research project has been approved by the SCU Human Research Ethics Committee

Participant’s name: ______________________________________________

Participant’s signature: ___________________________ Date: ___________

Please tick this box and provide your email or mail address below if you wish to receive a summary of the research when it is finished.

Email: _______________________________________________________