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Example Consent form

This can be used as a template to help in creating your own consent form. Replace the XXX with details of your own experiment.


XXX Experiment - Consent Form


Experiment Purpose & Procedure

The purpose of this experiment is XXX

The experiment consists of XXX parts as follows, during which you will be asked to XXX …

(If debriefing is involved) After the experiment, you will be asked to complete a questionnaire.

Please note that none of the tasks is a test of your personal intelligence or ability. The objective is to test the usability (or XXX) of our research systems



The following data will be recorded: XXX

All data will be coded so that your anonymity will be protected in any research papers and presentations that result from this work.

(If data is to be recorded that would identify the participant, for example photographs, audio or video, and if there is any intention to use this material in any publication or presentation, a separate release statement should be obtained after the recording has been made).


Finding out about result

If interested, you can find out the result of the study by contacting the researcher XXX , after date XXX. She can be contacted in room XXX. Her phone number is XXX and her email address is


(the following section can be torn off, and retained by researcher, with participant keeping above information)

Record of Consent

Your signature below indicates that you have understood the information about the XXX experiment and consent to your participation. The participation is voluntary and you may refuse to answer certain questions on the questionnaire and withdraw from the study at any time with no penalty. This does not waive your legal rights. You should have received a copy of the consent form for your own record. If you have further questions related to this research, please contact the researcher.


_________________ _________________
Participant Date
_________________ _________________
Researcher Date