Is there an associate between sleep apnea and self-reported cognitive decline among older adults aged 65 and older in the U.S.
Delete all instructions in red before submitting
Use this template for studies where the only activity is an online survey.
Instructions are in red. Customize the language in black as needed to fit your study. When you have finished, read over the entire document to ensure it makes sense and is accurate.
Use simple language. Avoid technical terms.
Write in a conversational tone, as though you’re speaking to your participants.
Use pronouns (I, we, you, they) and contractions (we’re, won’t, isn’t). The template default is “we”; you can change this to “I” if you’re doing the research entirely on your own.
Use short paragraphs (~4 lines or less). Don’t write walls of text.
Feel free to use bullet points, tables, graphs, pictures, diagrams, etc. to more clearly convey the study information.
Informed Consent to Participate in Research
Study title: [insert]
Researcher[s]: [insert name(s) and title / degree / department, as applicable]
We’re inviting you to take a survey for research. This survey is completely voluntary. There are no negative consequences if you don’t want to take it. If you start the survey, you can always change your mind and stop at any time.
What is the purpose of this study?
[describe the purpose or goals in simple language]
Examples: We want to understand the ways couples communicate in a marriage and divide chores. – or – We want to learn whether there is a connection between the amount of sleep and exercise university students get, and their stress levels and grades.
What will I do?
[Describe the survey topic(s) and the types of questions that will be asked. If there are any questions that participants could find objectionable, be sure to mention that here as well.]
Example: This survey will ask questions about your marriage, how you divide chores, and things you and your spouse enjoy doing together. It includes questions about your sex life and whether you have ever cheated on your spouse. The survey will take about 20 minutes.
Risks [customize as needed to fit your study]
Some questions may be personal or upsetting. You can skip them or quit the survey at any time.
Online data being hacked or intercepted: Anytime you share information online there are risks. We’re using a secure system to collect this data [elaborate if desired], but we can’t completely eliminate this risk.
Breach of confidentiality: There is a chance your data could be seen by someone who shouldn’t have access to it. We’re minimizing this risk in the following ways: [Use whichever of the following bullet points apply to your study. Add any other measures you’ll use to protect data security.]
Data is anonymous. – or – All identifying information is removed and replaced with a study ID.
We’ll remove all identifiers after [insert amount of time or specific event].
We’ll store all electronic data on a password-protected, encrypted computer.
We’ll keep your identifying information separate from your research data, but we will be able to link it to you. We’ll destroy this link after we finish collecting and analyzing the data.
Add any other risks – think about emotional, social, and/or financial risks.
Possible benefits: List individual benefits (if any). List benefits to a larger group or society (such as helping understand more about xyz). Don’t include compensation here; you’ll describe that below.
Estimated number of participants: [insert #. If needed, add explanation or description of different groups, e.g. 40 teachers and 300 students]
How long will it take? [insert total amount of time for individual participation]
Costs: None – or – describe any costs to participants
Compensation: [insert non or a small incentive that is not coercive] Due to institutional policy and IRS regulations, we may have to collect your name, address, or phone number to give you this compensation.
[If the only alternative is not to participate, delete this paragraph.] If I don’t want to be in this study, are there other options? Instead of participating, you can [insert alternative(s)] Example: Instead of participating, you can earn the same amount of extra credit by answering questions 1-2 on page 394 of your textbook.
Future research: De-identified data (all identifying information removed) may be shared with other researchers. You won’t be told specific details about these future research studies. – or – Your data won’t be used or shared for any future research studies.
[Use if research is funded] Funding source: [insert funding source]
Confidentiality and Data Security
[Include if applicable] We’ll collect the following identifying information for the research: [list. Examples: your name, email address, and the UNF class you’re enrolled in]. This information is necessary [explain why / what it will be used for. Example: This information is necessary so that you can receive extra credit].
Where will data be stored? [Explain] Example: On the researchers’ computers – or – On the servers for the online survey software (Qualtrics).
How long will it be kept? [insert amount of time]
Who can see my data?
We (the researchers) will have access to [insert type of data; Examples: identifiable (with your name included) – or – coded (names removed and labeled with a study ID) – or – de-identified (no names, birthdate, address, etc.)]. This is so we can analyze the data and conduct the study.
Agencies that enforce legal and ethical guidelines, such as
The Institutional Review Board (IRB) at the University of North Florida
We may share our findings in publications or presentations. If we do, the results will be [state the kind of data that will be included in dissemination of your work. Examples: aggregate (grouped) data, with no individual results – or – de-identified (no names, birthdate, address, etc.).] If we quote you, we’ll use pseudonyms (fake names).
[Delete if n/a] Our funding agency requires us to make our dataset public so other researchers can use it. This public dataset will include only [state the kind of data that will be included. Examples: aggregate (grouped) data, with no individual results. – or – de-identified (no names, birthdate, address, etc.).
Add anyone else who may potentially access the data. Describe the purpose of this disclosure, and what type of data (identifiable, de-identified, etc.).
Questions about the research, complaints, or problems: Contact [insert Researcher name(s), phone & email, or other best contact method].
Questions about your rights as a research participant, complaints, or problems: Contact [insert Researcher Institution’s IRB name(s), phone & email, or other best contact method – you will need to look this up].
Agreement to Participate
Your participation is completely voluntary, and you can withdraw at any time.
To take this survey, you must be:
At least 18 years old
[insert any other inclusion/exclusion criteria]
If you meet these criteria and would like to take the survey, click the button below to start.
Make this consent document the first question/page of your survey.
This Online Survey Consent Form template was adapted from the University of Wisconsin-Milwaukee available at https://uwm.edu/irb/consent-form-templates/
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