Principal Investigator:                                              Phone: 
Faculty Supervisor:      Dr. Patrick Withen               Phone:  276-376-4526
Human Investigations Commitee Chair:  Dr. Stan Kunigelis       Phone:  276-328-0202
Department of  Social Sciences, UVaWise, 1 College Ave., Wise, VA, 24293
Project Title:
Expected Duration:  This survey should take              to complete.

Purpose and Background:   You are invited to participate in a study of (state what is being studied).  I cam conducting this research because of my interest in this area, and as part of my Senior Capstone Porject in Sociology, which is a requirement for graduation from UVaWise.  I am examining (state what the study is designed to discover or establish.  Insert an santized version of your thesis statement here.).  You were selected as a possible participant in this study because (state why and how the subject was selected
Procedures:   If you decide to participate, I (your name) will (describe the procedures to be followed, including their purpose, how long they will take, and their frequency.)
Risks/Discomforts:   There are no measurable potential risks or discomforts involved in this survey other than anxiety caused by the survey questions. 
(Describe the discomforts and inconveniences reasonably to be expected as well as an estimate of the total time required.  Describe the risks reasonably to be expected.  Any standard treatment that is being withheld must be disclosed.)
Benefits:   There may be no direct benefit to you from participating in this study.  However, the information that I provide may help health professionals better understand how (what you expect to learn from your study.)  (Describe appropriate alternative procedures that might be advantageous to the subject, if any.)
Confidentiality:   Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission.  (If you will be releasing information to anyone for any reason, you must state the persons or agencies to whom the information will be furnished and the nature of the information to be purposed, and the purpose of the disclosure.)
Costs:  (If there is a possibility of additional costs to the subject because of participation, describe it.) 
Payment:  (If the subject will receive compensation or any other benefit, describe the amount or nature.)
Consent:   Your decision whether or not to participate will not affect your future relationships with (institution or agency).  If you decide to participate, you are free to discontinue participation at any time without affecting (your treatment, your care, your activities, your relationship).
 Questions:   If you have questions, please ask us.  If you have any additional questions later, (investigator’s name) will be happy to answer them.  If for some reason you do not wish to do this, you may contact the Chair of the HIC Kathleen Huttlinger, Smiddy Hall, room 243.
You will be offered a copy of this form to keep.
PARTICIPATION IN RESEARCH IS VOLUNTARY.  You are free to decline to be in this study, or to withdraw from it at any point.  Your decision as to whether or not to participate in this study will have no influence on your present or future status as a (patient, student, employee).
You are making a decision whether or not to participate.  Your signature indicates that you have read the information provided above and have decided to participate.  You may withdraw at any time after signing this form should you choose to discontinue participation in this study.

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Signature         Date

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(Signature of Parent or Legal Guardian)     Date
(This line should not appear on forms that will be given to subjects consenting for themselves.)

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Signature of Witness (when appropriate)    Date

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Signature of Investigator       Date