DEPARTMENT OF CORRECTIONAL SERVICES

CONSENT FORM

 

I the undersign, hereby willingly participate in this research project being undertaken by

 

[ Mr./ Mrs./ Miss ] ____________________________________________________ 

 

entitled _____________________________________________________________________

 

 

In agreeing to participate, I understand that:

 

  1. My anonymity will be preserved at all times because my name and any other identifying information will be kept strictly confidential; and the results of this report will be reported in such a manner that I will not be identifiable in anyway.

 

  1. I can refuse any question that I do not want to answer.

 

  1. I can discontinue participation in this research at any time and for any reason, without fear of negative consequences to me.

 

  1. The interviewer may request that the interview to be taped/videotaped.

 

Tick one of the following:

[     ] I agree that the interview may be recorded/video taped

[     ] I do not agree to have the interview recorded and videotaped

  1. The interviewer may request that photographs be taken of you.
  2.  
  3. Check the following:

[    ] I agree that the interviewer may take photographs of me

[    ] I do not agree that the interviewer may take photographs of me. 

  1.  

I __________________________ have read this consent form, been given the opportunity to ask questions, and all questions I have asked have been answered to my satisfaction.

 

In signing this consent form, I am agreeing to participate in this research project.

 

 

 

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Signature of Participant                                        Date

 

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Signature of Researcher/Interviewer                                Date

 

 

Signed in the presence of -------------------------------------------------------

                                                   for Superintendent

 

                                    ----------------------------------

                                                      Date