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Example-Consent Form

This consent form outlines an experiment being conducted at the Tech3Lab. It describes: 1) The research project aims to study an application/website/software under the supervision of Professor Pierre-Marjorique Léger. 2) The experiment will involve completing a questionnaire, performing a task, and an individual interview. Participant responses and reactions will be evaluated but no judgements will be made. 3) Data collection methods include optional video/audio recording of the experiment and pre/post questionnaires. Participation is voluntary and participants can withdraw consent at any time.

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Irgi Muttaqin Fahrezi
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219 views

Example-Consent Form

This consent form outlines an experiment being conducted at the Tech3Lab. It describes: 1) The research project aims to study an application/website/software under the supervision of Professor Pierre-Marjorique Léger. 2) The experiment will involve completing a questionnaire, performing a task, and an individual interview. Participant responses and reactions will be evaluated but no judgements will be made. 3) Data collection methods include optional video/audio recording of the experiment and pre/post questionnaires. Participation is voluntary and participants can withdraw consent at any time.

Uploaded by

Irgi Muttaqin Fahrezi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

CONSENT FORM – EXPERIMENT AT THE TECH3LAB

1. PRESENTATION OF THE RESEARCH PROJECT

We invite you to participate to a research project concerning the application/website/software.

This project is conducted under the supervision of professor Pierre-Marjorique Léger, whom you
can contact by phone at 514 340-7013 or by email at [email protected].

The project is funded by the [funding agency].

2. DESCRIPTION OF THE EXPERIMENT

During this experience, you will have to complete a short questionnaire on [to be completed].
Subsequently, you will have to perform [to be completed]. The experience will end with [to be
completed] followed by an individual interview.

During the experiment, you will have to answer questions. Your reactions will be evaluated but no
judgment will be made on them. Your first impression often best reflects your real opinion. Please
respond without hesitation. There is no time limit for completing the questionnaires.
[OPTIONAL]: You will receive a compensation of $ xx immediately after the end of the experience.

3. DESCRIPTION OF DATA COLLECTION TOOLS USED IN THIS EXPERIMENT

A) Data collection by video, audio and screen recording [OPTIONAL]


This experiment will be filmed. If you agree to be filmed, all videos will be confidential, password
protected and stored in a secure location. The videos will be used to analyze your actions and
conversations during the experience. These videos will never be published or rebroadcast publicly
in any way. Only researchers involved in this project will have access to it. You have the right to
refuse to have the experiment filmed. In this case, you will not be able to participate in the
user test.
B) Data collection by questionnaires
We will present you a questionnaire in an electronic format at the beginning and end of the
experience to collect data about your pre and post knowledge related to data science concepts. The
data collected are anonymous and will remain strictly confidential; they will only be used for
knowledge advancement purposes and the reporting of aggregated results in scholarly and
professional articles. You may refuse to answer the questionnaire, in which case, you will not
be able to participate in the experiment.
Your participation in this research project must be entirely voluntary. You may refuse to
answer any subsequent questions presented to you. It is also your right to ask to end the
experiment, which will prohibit the researcher from using the information collected. If you have
any questions concerning the ethics of the project, you may contact the secretary of the Research
Ethics Board (REB) or HEC Montréal by telephone at 514 340-7182 or by e-mail at [email protected]. Do
not hesitate to ask the researcher any questions you deem relevant.

CONSENT FORM
4. POSITIONING OF SENSORS

No sensors will be used in the experiment.

5. CONFIDENTIALITY OF COLLECTED DATA

The researcher, as well as other members of the research team, undertakes, where applicable, to
protect the personal information obtained in the following manner:
A. Ensuring the protection and security of the data collected from participants and keeping the
records in a secure location;
B. Discussing confidential information obtained from participants only with members of the
team;
C. By not using the data collected in this project for purposes other than those intended, unless
approved by the HEC Montréal REB. Note that your approval to participate in this research
project is equivalent to your approval to use the data for future projects that may be
approved by the HEC Montréal REB;
D. Not using, in any way whatsoever, the data or information that a participant has explicitly
asked to be excluded from the data collected.
All personnel that have access to the data collected have signed a form of confidentiality.
The REB and HEC Montréal have confirmed that the data collection related to this present study
satisfies the ethical norms in research involving humans.

6. CONDUCTING OF THE EXPERIMENT

This section specifies the conducting of the experiment.

 Before the start of the experiment, an explanation of the purpose of the research and how
the experiment will be carried out will be given to the participant.
 The participant will then have to sign the consent agreement, which presents the various
conditions of the experience.
 You will then have to complete a first online questionnaire on [to be completed].
 You will then be asked to perform a task on [to be completed].
 We will ask you to answer questionnaires to comment on your perception of the use of this
interface.

7. AFTER THE EXPERIMENT

 At the end of the experiment, participants will be asked to complete a post-experimental


questionnaire.
 There will also be a short individual interview (approximately [to be completed] minutes)
 You will be compensated in an amount of [to be completed] in cash (OPTIONAL).

CONSENT FORM
 A debriefing will also be offered to participants depending on the research context.

8. CONSENT OF THE PARTICIPANT

Are you UNDER the age of 18?

YES  NO 
Are you suffering from or have you suffered from epilepsy?

YES  NO 
Do you have a diagnosed health problem?

YES  NO 
Do you have a neurological or psychiatric diagnosis?

YES  NO 
If you have answered YES to one of these questions, you may NOT participate in this experiment.

CONSENT TO THE EXPERIMENT

The researcher, who is conducting this study, has explained to me what I will have to do
during the experiment and I agree to participate. My name or any other personally
identifiable information will not be released. I understand that any information I provide
will be kept strictly confidential. I further understand that my participation is voluntary
and that I am free to withdraw my consent and terminate my participation at any time
 I agree to participate in this experiment

 I do not agree to participate in this experiment

CONSENT TO AUDIO-VISUAL RECORDING [OPTIONAL]

The experiment will be recorded. If you agree to be recorded, all videos will be confidential,
protected by a password and kept under lock and key. The videos will be used to analyze
your actions and conversations during the experiment. These videos will never be
published or publicly disseminated in any way. Only the researchers involved in the project
will have access to them.
 I agree to participate in this experiment

 I do not agree to participate in this experiment

CONSENT FORM
9. SIGNATURES OF THE PARTICIPANT AND THE RESEARCHER

First and last name of the participant : ________________________________________________


Signature of the participant: _____________________________ Date (dd/mm/yyyy): _______________
(The participant must keep a copy of this form)

First and last name of the researcher : ________________________________________________


Signature of the researcher : ______________________________ Date (dd/mm/yyyy): ______________

CONSENT FORM

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