Sample informed consent forms

For guidelines on creating informed consent forms, see the Cornell University Committee on Human Subjects (UCHS) website.

Here are two samples of consent forms we have used in the past. You may adapt them for your own use.

Sample 1


[Name and address]

Dear _______:

I’m writing to ask if you’d allow me to interview you on [date].

For a dozen years or more now, I have worked with my students at Cornell to produce teaching materials based upon Studs Terkel-like first person voice “profiles” of practitioners talking about their work in real cases. Students in classes find these materials rich, accessible, illuminating, and very useful.

Our mediator interviews focus upon your work as a third party, not the case as a whole: how you began, how you handled the tasks and challenges and surprises at hand, how you improvised, how you worried and handled those worries, how you turned a corner at critical moments, how you failed at X and succeeded at Y, how you achieved any instructive, desired outcome, what you learned in the process, what you’d do differently “next time,” how third parties can do this work better. So those “how questions” are what I hope to ask you about—if you’re willing—in a case that I’d ask you now to select: a case that you’ve found challenging, intriguing, and revealing the real work you do.

Our interviews are confidential and subject to your control. You have the right of first refusal: if you want to strike a line, a paragraph, a section, or the whole interview—we eliminate that line, paragraph, section, or the whole interview. We will tape record the interview, but nothing happens with the tape unless you expressly approve it.

Here’s how we do it. I will ask you about your work in the case you’ve chosen, and we’ll tape record our conversation. The tape will go into a queue that’s time and funding-dependent, and a student assistant at Cornell will transcribe the tape. I will edit the resulting transcript for sentence fragments, “ums and ahs,” and transcription problems: I will not change your words. I’ll create paragraph breaks to make the transcript more readable and to help the reader follow your account.

Then the transcript comes right back to you for your review, for any clarifications or deletions you wish to make, and for your possible approval for student use. If you’ve decided that the passage about Smith’s losing it in a meeting needs to be changed somehow, here’s the chance to do that (or to delete it). If you remember a crucial line that Smith said to change the whole flow of the meeting, this is the time to put it in.

If you find your transcribed and edited “practice story” now appropriate to share with students in the classroom or in trainings, this can also be the time to approve that “profile” for whatever distribution you find acceptable. In the past, our profiles have been used in universities and planning school classrooms in the Americas, Europe, the Mid-East, and Australia (at least), as well as in some dispute resolution trainings.

Because students say that they have learned a great deal from these first person voice accounts, I hope you’ll consider exploring the challenges of your work with me—so that students in turn will be able to consider those challenges, how you handled them, and how they might act in any similar situations in the future.

Finally, should I, as a matter of my on-going research, wish at any future time to write about any material contained in your profile, I will of course ask for your express permission to do that.

Our interviews should take about an hour, perhaps a bit more. If you’re willing to explore a case of your third-party practice with me, would you just sign below on a copy of this letter and return it to me?

Many thanks for your consideration. If you’re willing, I’m very much looking forward to talking to you.

With all best wishes,

John Forester                                                                     Professor                                                                       

111 West Sibley Hall

Cornell University

Ithaca, NY 14853


If OK, your signature here: __________________________________

Date: _____________________


Sample 2

Return the signed form – and direct any questions about this research – to:

Professor Scott Peters

Department of Education, 417 Kennedy Hall,

Cornell University, Ithaca, N.Y. 14853

(607) 255-9713  or  <>

Project Description:

This ongoing research study seeks to better understand the practice of community education and development by exploring the day-to-day work of professional educators. It also seeks to provide educators with the opportunity to reflect on that work so as to deepen their own understandings of extension/community education and to strengthen their professional skills.

Should you agree to participate, you will be asked to select a recent work-related project to talk about, and to recount your involvement with it. The interview will take place by telephone (or in person when distance permits). Interviews typically last about an hour and a quarter. In some cases, short follow-up interviews may be requested. The interview will be conducted either by Professor Scott Peters or by a Cornell graduate student working with him. All interviews will be tape-recorded, transcribed, and edited into “practitioner profiles.” (Some of the interviews will be transcribed by a professional transcriptionist. Beyond that, the tape-recorded interviews, the transcriptions, and the final profiles will be seen only by Professor Peters and the interviewer.) You will have the opportunity to review a draft of the edited profile and will be invited to correct, amend, or delete any of the information included. You may also request that the profile appear only under a pseudonym.

You may also be asked for your permission to allow us to use your profile in a class with Cornell graduate students and/or in a professional development workshop, or to allow excerpts from your profile to be quoted in an academic paper or professional presentation. You are under no obligation to agree.

Some participants may also be invited to take part in professional development workshops or seminars, using selected “practitioner profiles” as a tool for reflection. Again, agreement to be interviewed puts you under no obligation to take part in any additional activities.

Your participation in this study is voluntary.


The study has been described to me. I understand that my participation is voluntary and that I am free to withdraw my consent and discontinue my participation in the project at any time without penalty. I understand that either the interviewer or a professional transcriptionist will listen to the tapes and type up the conversation we had. (These records will be kept confidential.) I also understand that the interview transcript will be edited into a “practitioner profile” and that I will have a chance to review, correct, amend and approve (or not approve) the written profile. Finally, I understand that the final profile – in whole or in part – will not be shared with any one (beyond the interviewer and primary researcher, Professor Scott Peters), nor will it be cited in published articles or professional presentations, without my explicit permission. Such permission will be sought after the profile has been completed and approved.

I have read and understood the above information, and I consent to participate in this study by signing below.


Signature:                                                                                        Date: