Sample Information Release Form (Consent Form)

Description

Whenever an evaluator, or researcher, is focusing and reporting on personal information about a research subject, he or she should obtain permission from the subject to do so. The following form can be used as a sample. The final version of the form depends on the nature of the evaluation or research.

Sample Form

I voluntarily agree to participate in the evaluation of the ABC program. I understand that this evaluation is being conducted by Carter McNamara, the Program Director, to improve the ABC program and is also the basis of his doctoral dissertation. I understand that the evaluation methods which may involve me are:

1. the Program Director’s recorded observations of my circle and its process and/or

2. my completion of evaluation questionnaire(s) and/or

3. my participation in a 30-60 minute interview.

I grant permission for the interview to be tape recorded and transcribed, and to be used only by Carter McNamara for analysis of interview data. I grant permission for the evaluation data generated from the above methods to be published in an evaluation report to the funder, The McKnight Foundation, and in the dissertation and future publication(s).

I understand that any identifiable information in regard to my name and/or agency name may be listed
only in the above-mentioned evaluation report to the funder, that is, this information will not be listed in the dissertation or any future publication(s).

_______________________________________
Research Participant

_______________________________________
Date

For the Category of Evaluations (Many Kinds):

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