Consent Form
Title: Media influences on perceptions of self
Researchers: Jane Student and John Faculty, Ph.D.
The purpose of this research project is to study the influence of television and fashion magazines on how women perceive themselves. We are asking you to fill out questionnaires that ask about the television shows and magazines you like to watch and feelings about yourself. Completion of the questionnaires should take about 15 minutes.
All information is anonymous. There are no known risks to participating. Participation in this study is completely voluntary and will have no effect on your grade.
You may choose to withdraw (stop) at any point without penalty. You do not need to
answer any question that makes you uncomfortable.
If you have any question regarding your rights as a participant, please contact Dr. Ethics
at (631) 555-ETHC. If you have any questions about the study or would like to get a
copy of the results, please contact Dr. Supervisor at (631)-555-STDY
________________________________________________________________
Name of participant (print)
________________________________________________________________
Signature of participant
Dominique Treboux, Ph.D. 