[Title of Project]

You are being invited to participate in a study entitled [TITLE] that is being conducted by [INVESTIGATORS]. 

[INVESTIGATOR] is a [RELATIONSHIP WITH THE UNIVERSITY…E.G., FACULTY MEMBER GRADUATE STUDENT] in the department of [DEPARTMENT NAME] at the University of Victoria and you may contact [HIM/HER/THEM] if you have further questions by [INCLUDE CONTACT INFORMATION].

[FOR STUDENTS ONLY, INCLUDE THE FOLLOWING:]
As a [GRADUATE OR UNDERGRADUATE] student, I am required to conduct research as part of the requirements for a degree in [DEGREE NAME]. It is being conducted under the supervision of [NAME OF SUPERVISOR]. You may contact my supervisor at [PHONE NUMBER].

[IF APPLICABLE INCLUDE THE FOLLOWING:]
This research is being funded by [NAMES OF FUNDING AGENCIES].

The purpose of this research project is [STATE THE PURPOSE AND OBJECTIVES]. 

Research of this type is important because [STATE WHY THE RESEARCH IS IMPORTANT AND THE CONTRIBUTION IT WILL MAKE].

You are being asked to participate in this study because [WHY AND HOW PARTICIPANTS WERE SELECTED].

If you agree to voluntarily participate in this research, your participation will include [DESCRIBE WHAT IS INVOLVED, INCLUDING PROCEDURES, METHODS, TIME COMMITMENTS, LOCATION, ETC.]. STATE THE APPROXIMATE NUMBERS OF PARTICIPANTS INVOLVED IN THE STUDY

Participation in this study may cause some inconvenience to you, including [POTENTIAL OR KNOWN INCONVENIENCES ASSOCIATED WITH PARTICIPATION]. 

[YOU MUST STATE ONE OF THE FOLLOWING:]
1.	There are no known or anticipated risks to you by participating in this research.  [OR]
2.	There are some potential risks to you by participating in this research and they include [DESCRIBE RISKS, E.G., EMOTIONAL, SOCIAL, PSYCHOLOGICAL, PHYSICAL, ECONOMIC, ETC.]. To prevent or to deal with these risks the following steps will be taken [STATE HOW YOU WILL DEAL WITH RISKS].

The potential benefits of your participation in this research include [STATE THE BENEFITS OF THIS RESEARCH, AS APPLICABLE: TO PARTICIPANTS; TO SOCIETY; TO THE STATE OF KNOWLEDGE].

[IF APPLICABLE INCLUDE THE FOLLOWING:]
As a way to compensate you for any inconvenience related to your participation, you will be given [DESCRIBE ANY FORM OF PAYMENT, CREDIT, ETC.]. It is important for you to know that it is unethical to provide undue compensation or inducements to research participants and, if you agree to be a participant in this study, this form of compensation to you must not be coercive. If you would not otherwise choose to participate if the compensation was not offered, then you should decline.

Your participation in this research must be completely voluntary. If you do decide to participate, you may withdraw at any time without any consequences or any explanation. If you do withdraw from the study your data will [DESCRIBE WHAT WILL HAPPEN TO THE DATA – E.G., IT WILL: NOT BE USED; IMPOSSIBLE TO REMOVE FROM DATA BASE; USED ONLY IF PARTICIPANT GIVES PERMISSION]. [ALSO DESCRIBE WHAT WILL HAPPEN TO ANY COMPENSATION]

[IF APPLICABLE INCLUDE THE FOLLOWING:]
The researcher may have a relationship to potential participants as [STATE THE RELATIONSHIP, E.G., TEACHER/STUDENT; THERAPIST/CLIENT; SUPERVISOR/EMPLOYEE]. To help prevent this relationship from influencing your decision to participate, the following steps to prevent coercion have been taken [EXPLAIN HOW COERCION WILL BE PREVENTED].

[IF APPLICABLE INCLUDE THE FOLLOWING:]
To make sure that you continue to consent to participate in this research, I will [EXPLAIN HOW YOU WILL HANDLE ONGOING CONSENT; THIS IS PRIMARILY AN ISSUE IN RESEARCH THAT OCCURS OVER MULTIPLE OCCASIONS OR AN EXTENDED PERIOD OF TIME].

[IF APPLICABLE INCLUDE THE FOLLOWING:]
This research may lead to a commercial product or service. The nature of this commercial use is [DESCRIBE].

In terms of protecting your anonymity [DESCRIBE HOW WILL ANONYMITY BE PROTECTED; OR JUSTIFY WHY LOSS OF ANONYMITY IS REQUIRED].

Your confidentiality and the confidentiality of the data will be protected by [EXPLAIN HOW CONFIDENTIALITY WILL BE PROTECTED; HOW WILL CONFIDENTIAL DATA BE STORED; OR JUSTIFY THE LACK OF CONFIDENTIALITY.  DESCRIBE WHAT PERSON(S) OR ORGANIZATIONS WILL HAVE ACCESS TO PERSONALLY IDENTIFIABLE DATA. EXPLAIN IMPLICATIONS FOR ANY PERSONAL IDENTIFYING INFORMATION LEAVING CANADA].

It is anticipated that the results of this study will be shared with others in the following ways [DESCRIBE HOW YOU ANTICIPATE DISSEMINATING THE RESULTS, E.G.: DIRECTLY TO PARTICIPANTS; PUBLISHED ARTICLE; THESIS/DISSERTATION/CLASS PRESENTATION; PRESENTATIONS AT SCHOLARLY MEETINGS; OTHER – SPECIFY.  STATE CLEARLY IF PARTICIPANT WILL/WILL NOT RECEIVE RESULTS OF STUDY]

Data from this study will be disposed of [DESCRIBE WHEN AND HOW DATA WILL BE DESTROYED, E.G., ELECTRONIC DATA WILL BE ERASED; PAPER COPIES WILL BE SHREDDED].

[IF APPLICABLE INCLUDE THE FOLLOWING:]
Individuals that may be contacted regarding this study include [RESEARCHER, CO-INVESTIGATORS, SUPERVISOR; PROVIDE CONTACT INFORMATION, OR REFER TO THIS INFO AT BEGINNING OF CONSENT FORM].

In addition to being able to contact the researcher [AND, IF APPLICABLE, THE SUPERVISOR] at the above phone numbers, you may verify the ethical approval of this study, or raise any concerns you might have, by contacting the Human Research Ethics Office  at the University of Victoria at 250-472-4545 or ethics@uvic.ca  and the VIHA Research Ethics office at 250-370-8620.

Your signature below indicates that you understand the above conditions of participation in this study and that you have had the opportunity to have your questions answered by the researchers.

					
Name of Participant		Signature		Date	

A copy of this consent will be left with you, and a copy will be taken by the researcher.