SAMPLE/TEMPLATE: CONSENT PREAMBLE for SURVEY and or INTERVIEW
Are you conducting a survey and or interview?
A. Yes:_____
B. No:______
Please copy the appropriate template (A and or B) below into your own document and
use as needed.
A. CONSENT PREAMBLE for SURVEY
You have been asked to complete this survey as part of a research project conducted by, [INSERT
PI/SI NAME], a [STUDENT, FACULTY, OR STAFF MEMBER] at Howard University, in Washington,
DC.
The research project is called [TITLE OF PROJECT]. The study is designed to [DESCRIBE PURPOSE
OF STUDY]. You are being asked to participate in this because [INSERT DESCRIPTION OF WHY
PARTICIPANT WAS SELECTED]. Your responses are entirely voluntary, and you may refuse to
complete any part or all of this survey. This survey is designed to be anonymous, meaning that
there should be no way to connect your responses with you.
Toward that end, please do not sign your name to the survey or include any information in your
responses that makes it easy to identify you. By completing and submitting the survey, you affirm
that you are at least 18 years old and that you give your consent for [INSERT PI/SI NAME] to use
your answers in their research. If you have any questions about this research before or after you
complete the survey, please contact [PI NAME and PI CONTACT INFO]. If you have any concerns or
questions about your rights as a participant in this research, please contact the Howard University
Institutional Review Board.
B. CONSENT PREAMBLE for INTERVIEW
You have been asked to participate in this interview as part of a research project conducted by me,
[INSERT PI/SI NAME], a student/Faculty member at Howard University, in Washington, DC.
The research project is called [INSERT TITLE]. The study is designed to [DESCRIBE PURPOSE OF
STUDY]. You are being asked to participate in this because [INSERT DESCRIPTION OF WHY
PARTICIPANT WAS SELECTED].
Your responses in this interview are entirely voluntary, and you may refuse to answer any or all of
the questions in this interview. I expect that the interview will last approximately [INSERT
ESTIMATED DURATION OF PARTICIPATION]. By agreeing to participate in the interview, you
affirm that you give your consent for me, [INSERT PI/SI NAME], to record this interview and to use
your answers in my research. All responses will be anonymized, and there will be no way to trace
your responses back to you. If you agree to participate, you will receive [INSERT DESCRIPTION OF
STUDY BENEFITS OR STATE THAT THERE ARE NO DIRECT BENEFITS]. The risks to
participating in this study include [INSERT DESCRIPTION OF RISKS OR STATE THAT THERE ARE
NO KNOWN RISKS].
If you have any questions about this research before or after you complete the survey, you can
contact me [INSERT PI/SI CONTACT INFO]. I will give you this contact information in written form
at the end of the interview.
If you have any concerns or questions about your rights as a participant in this research, you can
contact the Howard University Institutional Review Board at theorrc@howard.edu or (202) 865-
8597. I will also give you this contact information in written form at the end of the interview.
Do you confirm that you are over 18 years old? Do you give your consent to participate in this
interview?
