Informed Consent Form
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Instructor
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Date of Submission
Informed Consent Form
My name is _________________ and I am a _________________ student at _________________. I am requesting your participation in a research study entitled “Clinical Laboratory Science (CLS) Students’ Perceived Preparedness for Future Career Goals.” The purpose of this study is to investigate CLS students’ confidence in the CLS program curriculum to fully prepare them for their desired career path, either within the CLS field or another related healthcare field in the future.
Voluntary Participation
Participation in this research study is completely voluntary and is not a requirement of the program. If you volunteer to participate in this study, you will be requested to do the following:
- Complete a short demographic questionnaire that includes questions such as your age and educational history. The questionnaire will take 10 minutes of your time.
- Complete a survey that includes questions about your immediate and long-term career goals including your intention to work in the CLS field after graduation or to pursue another career path within the healthcare arena. There will also be questions about each course in the CLS curriculum and your opinion of its effectiveness in preparing you for your future goals. The survey will take 30 to 45 minutes of your time.
Benefits
Participants of this study will be recruited from among enrolled juniors and seniors of the CLS program at _________________. You will earn 5% extra credit for every 60 minutes that you participate in this study which can be applied to one of your CLS courses being taken during the current semester. There is no monetary compensation for participation in this research study.
Refusal to Participate
If you do not wish to participate, you will not be penalized and you will not be treated differently from students who participate. You will not lose any other benefits beside the extra credit granted to participants.
Withdrawal from the Study
There is no penalty for withdrawal from the study. You will still receive the extra credit granted to participants who complete the study. There will be no penalty to you if you agree to participate but withdraw your participation before the start of the study.
Risks
This study poses minimal or no risk to the participant. There is the potential for emotional discomfort while recalling or describing courses that may not have met the student’s expectations of preparedness. There is also the potential for participants to experience fear or anxiety that opinions about specific courses will be discovered by program faculty/administrators and lead to victimization. If any question causes you discomfort, you are not obligated to provide an answer. You may stop taking the survey at any time and withdraw from the study.
Confidentiality
All information provided will be kept confidential to the extent permitted by law. A pseudonym will be used to protect your identity. I will be the only person with access to your information; no one else, including other faculty members or administrators of the CLS program, will have access to your information. I will secure your information using the following procedures:
- Locking it in a filing cabinet to which I alone have access
- Storing computer files on a password-protected portable hard drive
Your information will be stored for three years, after which all papers and electronic data will be destroyed.
The results of this study will assist in understanding the student’s perspective regarding the effectiveness of the CLS curriculum in career preparation. When the results are shared as publications in peer-reviewed journals, your name will not be included, group averages will be used, and there will be no indication that you were a participant in this study based on the presentation of the data.
Contact Information:
If you have questions, please do not hesitate to contact me at [insert email] or [phone number]. You may also contact the Institutional Review Board point of contact, Dr. Due Diligence, at (xxx) xxx-xxxx.
Signature
Your signature indicates that:
- You understand all of the information contained within this consent form.
- You agree to participate in this research study.
- I have discussed this consent form with you and have answered all of your questions.
You will be given a copy of the form for your records.
_______________________ _______________________ ________________
Participant Signature Printed Name Date
_______________________ _______________________ ________________
Researcher Signature Printed Name Date
References
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ). (2012). The AHRQ informed consent and authorization toolkit for minimal risk research. Retrieved from https://www.ahrq.gov/funding/policies/informedconsent/icform1.html
