Evaluation Toolkit for Breastfeeding Programs and Projects

June 2012

Appendix F – Sample consent form template

Page last updated: 04 November 2013

These instructions can be deleted once you have finalised your document.)

You can use this type of form when you are asking service users to participate in research. It is good practice to provide participants with an information sheet which they can keep, which will tell them what the evaluation is about, what will happen to their information, and how you will maintain their privacy. If you require ethics approval you will certainly need to create a consent form, which should also include an option for people to withdraw from the project (see page 56).

The information sheet should contain the following information at a minimum:

  • what the project is about
  • who is undertaking the project (including name and contact details of a nominated representative)
  • what information is being collected and why
  • what information the service user will be asked to supply and why
  • what will happen to that information
  • what impact participating (or not participating) will have on the service user
  • how to give consent, and how to withdraw
  • where to go for more information or to make a complaint

Sample Constent Form

Consent statement

(These instructions can be deleted once you have finalised your document.)

Put this on a separate page from the information sheet as the evaluators will keep this signed statement.

I have read (or had read to me) and understood the information provided to participants on the information sheet about the evaluation of the [name of project]. Any questions I have asked have been answered to my satisfaction. I agree to participate in this interview, as described. I understand that this interview is voluntary, and that I can withdraw my consent at any time.

I understand that information about me will be collected by the researcher I speak to, and that my name will be taken off this information later so that no one will know what I have said. I understand that the report will not include any details which might identify me to others.

Name of Participant
Signature
Date

Name of Researcher
Signature
Date

Sample Constent Form

Withdrawal of Consent

(These instructions can be deleted once you have finalised your document.)

Put this on a separate page from the information sheet or consent form, so that the participant can send it in later if they want to – the participant takes this away with them, along with the information sheet.

I hereby withdraw my consent to take part in the evaluation of the [name of project]. I understand that my withdrawal will not be made known to local services and that my choice not to participate will have no influence on present or future health or other services I may choose to use.

I understand that all the notes taken at my interview will be withdrawn from the study and destroyed at this request.

Name of Participant
Signature
Date

Please return this form to [give contact details]