Signature Assignment - Leader Interview and Synthesis

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ldr711a_v11_consent_form.docx

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LDR/711A v11

Title

ABC/123 vX

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Interview Consent Form

I _____________________________________(interviewee’s name) agree to participate in an interview discussion for a class assignment. I understand the assignment and the types of questions I will be asked to answer.

I understand that my participation is completely voluntary and that I can decline to participate, without consequence, at any time during the interview. I understand that with my consent the interview may be recorded and that the information I provide will remain confidential and used only for the purposes of completing this assignment.

I understand that the results from this interview will be used exclusively for this assignment and will not be published in any form.

I also understand that there are no risks involved in participating in this activity, except risks experienced in daily life.

Interviewee name (please print): ________________________________________________________

Signature:__________________________________________________________________________

Date:_____________________

Student name: _____________________________________________________________________

Student contact telephone number: __________________________

Student email address: _____________________________________________________________