Interview Consent Form printable pdf download

INTERVIEW CONSENT FORM

Project Title: In the Margins or the Mainstream? Gay and Lesbian

IRB Protocol #

Narratives about Urban Space, Place, and Daily Life

13704

Principal Investigator: Julia A. Ericksen, Department of Sociology, Temple University,

Philadelphia, PA, 19122. (215) 204-8065. julia@temple.edu

Student Investigator:

Daniel T. Schermond, Department of Sociology, Temple University,

Philadelphia, PA, 19122. (215) 326-9609. dschermond@temple.edu

I am currently engaged in a study about places in the city where gay men and lesbians live and

congregate. I am interviewing people to learn what they think about where they live, work,

interact with others, and connect with their communities. To further my investigation I would

like to interview you about your personal experiences both currently and in the past. I will ask

you about the extent to which you think of your sexuality as related or unrelated to these. The

interview will last from one to two hours depending on the extent of your experience.

All documents and information pertaining to this research study will be kept confidential, unless

required by applicable federal, state, and local laws and regulations to be disclosed. Understand

that records and data generated by the study may be reviewed by Temple University and its

agents, the study sponsor or the sponsor’s agents (if applicable), and/or governmental agencies to

assure proper conduct of the study and compliance with regulations. The results of this study

may be published. If any data is published, you will not be identified by name. You will be

identified only in general terms, such as: “a 34 year-old lesbian/gay man living in Northeast

Philadelphia.” Alternatively, I may represent you through the use of a pseudonym. You may, if

you wish, sign an alternative consent form waiving your right to anonymity.

I welcome questions about the study at any time. Your participation in this study is on voluntary

basis, and you may refuse to participate at any time without consequence or prejudice. Questions

about your rights as a research subject may be directed to the Institutional Review Board

Coordinator by phone at (215) 707-3390, by email at IRB@temple.edu, or by regular mail:

Institutional Review Board Coordinator, Temple University Research Administration, Student

Faculty Conference Center, 3340 North Board Street – Suite 304, Philadelphia, PA 19140.

Signing your name below indicates that you have read and understand the contents of this

Consent Form, you have received a signed copy, and that you agree to take part in this study.

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Participant’s Printed Name

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Participant’s Signature

Date

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Investigator Signature

Date

Interview Consent Form