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Name of Researcher: Contact information for Researcher: I understand that I am being interviewed and recorded for a newspaper article

project conducted by ___________________ (name of student researcher) for ____________ (class) at ___________________ (school) taught by ____________________ (name of teacher). I agree to let him/her use the interview to write a paper for the class. It will not be used for any other purpose. I have been informed that if I become uncomfortable at any time during the interview, I do not have to answer questions or I can ask to have the tape or video recorder (if used) turned off. I am aware that I can request that a pseudonym (fake names) be used. I understand that by signing this form, I give permission for the interview to be used for the purposes stated above. Do you agree to participate in the interview ( ) YES ( ) NO Can the interview be recorded? ( ) YES ( ) NO Should a pseudonym be used? ( ) YES ( ) NO Signed: _______________________________________________________ Date: ___________________

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