Sample Consent Form printable pdf download

Sample Consent Form

Below is a sample consent that can be used for conducting your CLEAR sessions. You are

encouraged to use this consent so that participants are informed about the intervention and

have a opportunity to indicate their willingness to participate. Please adapt this sample

consent to meet you agency’s requirements and needs.

Title: CLEAR

Description: CLEAR is a multiple session intervention which is conducted one-on-one. The goal

of CLEAR is to help clients maintain health, reduce transmission and acquisition of HIV and

other STDs and improve their quality of life.

Risk and Benefits: There is no risk for participation. The benefit to you from participating is

improved health and quality of life.

Costs and Payments: You will receive (insert incentive description) for taking part in (insert

number) individual sessions. Incentives will be distributed (insert how participants will receive

incentives).

Confidentiality: Any information obtained about you as a result of participation in CLEAR will be

kept confidential (only made available to agency staff on a need to know basis). Such

information which will carry personal identifying material will be kept in locked files.

Voluntary Consent: I certify that I have read the above or it has been read to me and I

understand its contents. Any questions I have pertaining to CLEAR have been or will be

answered. A copy of this consent form will be given to me. My signature below means that I

promise to follow the rules of CLEAR and I freely agree to participate in the CLEAR sessions.

_________________________

_____________

Participant Signature

Date

_________________________

_____________

(Organization) Staff Signature

Date

Sample Consent Form