INFORMED CONSENT TEMPLATE
Page 1 of 3
INFORMATION ABOUT:
Emotional overeating awareness study
PRINCIPAL INVESTIGATOR:
Jennifer DiBernardo
CO-INVESTIGATORS:
Beth Herold
PURPOSE:
The purpose of this study is to increase the awareness of emotional influence on eating habits,
specifically over eating.
DURATION:
The duration of this program will be from October 1st through October 9th, 2015.
PROCEDURES:
1.A pretest will be distributed to participants to assess their existing perception
about their eating habits and behaviors associated with eating.
2.Participants will take part in a 7-day journaling activity documenting their
daily eating behavior.
3.Posttest will be conducted at the conclusion of the journaling exercise to
evaluate recognized negative eating behaviors and emotional triggers.
POSSIBLE RISKS OR DISCOMFORTS:
There are no potential risks from this project. If any questionnaire items produce discomfort, the
subjects are free to choose not to respond to that question.
POSSIBLE BENEFITS:
Participants have the potential benefit of increased awareness of causes of overeating, emotional
influences, and related preventive behavior.
FINANCIAL COSTS:
There is no financial cost to you as a participant in this research study.
12/14/2015
Page 2 of 3
ALTERNATIVE PROCEDURES/TREATMENTS:
No alternative procedures are available if you elect not to participate in this study.
VOLUNTARY PARTICIPATION:
You decide whether or not to take part in this study. If you choose to participate in this study, you
will be asked to sign the consent form. After you sign the consent form, you are still free to
withdraw at any time and without giving a reason. If you withdraw from the study before data
collection is completed, your data will be returned to you or destroyed.
CONTACT FOR QUESTIONS:
If you have any questions regarding this study, you may contact Jennifer DiBernardo at 123-456-
7890. You may also contact Beth Herold at 555-444-3333 if you have any questions concerning
your rights as a program participant or research subject.
INJURY/COMPLICATIONS:
No injuries or complications are likely to be caused by this study.
COMPENSATION FOR MEDICAL TREATMENT:
This study does not include any medical treatment.
CONFIDENTIALITY:
Your responses to this survey will be anonymous. Every effort will be made by the researcher to
preserve your confidentiality including the following: Code names/numbers will be assigned for
participants to be used on all research notes and documents. Notes, pre and post test and any
other identifying participant information will be kept in a locked file cabinet. Participant data
will be kept confidential except in cases where the researcher is legally obligated to report
specific incidents. These incidents include, but may not be limited to, incidents of abuse and
suicide risk.
12/14/2015
Page 3 of 3
CONSENT AND RELEASE:
By signing below, I certify that I have read or have had this document read to me. I have also
been given a signed copy of it. I acknowledge that I have been given the chance to ask questions
and to discuss my participation in this study. I freely and voluntarily choose to participate in this
study and release any data collected from me for use by investigators in an anonymous and
confidential manner.
____________________________________________________________________________________________
SIGNATURE OF PARTICIPANTDATE
_____________________________________________________________________________________________
SIGNATURE OF INVESTIGATORDATE
_____________________________________________________________________________________________
SIGNATURE OF WITNESSDATE
