Bard                          Institutional Review Board

Example Interview Consent Form

Whenever feasible, researchers should use consent forms when conducting interviews.  Here is an example of what an interview consent form might look like.  Note: Text marked [in brackets] is for your information and should not be included in your form.  Adaptation of this template should be discussed with your superviser.   (This template is adapted from this form, provided by Malaspina University-College.)

Factors Leading to Religious Conversion [Title]

I am a student at Bard College, and I am conducting interviews for my Senior Project.  I am studying the cultural and spiritual factors that lead to religious conversion. [Purpose]

During this study, you will be asked to answer some questions as to why you converted to your current religion.  This interview was designed to be approximately a half hour in length [Estimated Duration].  However, please feel free to expand on the topic or talk about related ideas.  Also, if there are any questions you would rather not answer or that you do not feel comfortable answering, please say so and we will stop the interview or move on to the next question, whichever you prefer.  [Description]

All the information will be kept confidential.  I will keep the data in a secure place.  Only myself and the faculty superviser mentioned above will have access to this information. Upon completion of this project, all data will be destroyed or stored in a secure location.  [Confidentiality; indicate what will become of data]

Participant's Agreement:

I am aware that my participation in this interview is voluntary.  I understand the intent and purpose of this research.  If, for any reason, at any time, I wish to stop the interview, I may do so without having to give an explanation.

The researcher has reviewed the individual and social benefits and risks of this project with me [Students should review minimal risks checklist prior to interview].  I am aware the data will be used in a Senior Project that will be publicly available at the Stevenson Library on the Bard College Campus.  I have the right to review, comment on, and/or withdraw information prior to the Senior Project's submission.  The data gathered in this study are confidential with respect to my personal identity unless I specify otherwise.  [If participant is being tape recorded:]   I understand if I say anything that I believe may incriminate myself, the interviewer will immediately rewind the tape and record over the potentially incriminating information.  The interviewer will then ask me if I would like to continue the interview. 

If I have any questions about this study, I am free to contact the student researcher ([Fatima Weiss,, 845-777-8888] ) or the faculty adviser ([Prof. Chris Cross,, 845-758-0000]).  If I have any questions about my rights as a research participant, I am free to contact the chair of Institutional Review Board:  Yuval Elmelech, Ph.D. (;, 845-758-7547).

I have been offered a copy of this consent form that I may keep for my own reference.

I have read the above form and, with the understanding that I can withdraw at any time and for whatever reason, I consent to participate in today's interview.

_______________________                       ___________________
Participant's signature                                         Date

Interviewer's signature

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