- Sample Consent Form – The 3302 Stroop study is IRB-exempted.

However, this is what

the form would look like when a consent form is required by the IRB (research other than
classroom studies, non-harmful surveys and natural observation research). The blue font
shows the 10 fundamental issues currently addressed in a consent form. Know these 10 for
exam purposes (Your textbook shows 8, but latest IRB rules have also added the last two).
Professor Harvey Ginsburg, Texas State University Department of Psychology is
conducting this investigation. The purpose of this study is to examine Stroop phenomenon
(color naming) and practice effects . The study requires about 10-15 minutes of your time.
You will be asked to complete 3 computer-generated sets of 20 trials each. Some of the trials
will show you a congruent word and color (word ‘red’ and in red font) or an incongruent
word and color (word ‘red’ but in blue font)You may be asked to provide some
biographical information. (1) informing participants about purpose, duration
& procedures )
If participating in a study about practice effects and reaction time to congruent or
incongruent words and font colors makes you feel uncomfortable for any reason, do not
participate. If you decide to participate, this study will measure reaction times to
computerized presentations of colors and words.
You are not under any obligation to participate and you have the right to (2) refuse
to participate or to withdraw from the research at any time. If you elect to
not participate, you may do an optional written assignment. Your participation is voluntary
and refusal to participate will involve no penalty or loss of benefits to
which you are otherwise entitled (3) possible consequences of
refusal/withdrawal). You may discontinue participation at any time without penalty
or loss of benefits. If you don’t want to take part in this study, you can still obtain the same
credit by writing a 14 page, double-spaced paper about Stroop research. The alternative
paper will be due at the same time as the written paper is due.
The IRB has affirmed that the potential for harm from participation is
minimal. You may experience some minimal fatigue or boredom. (4)
potential risks, discomfort or adverse psychological effects are stated
The (5) benefits are learning about the Stroop and practice effects.
Participants responses will remain (6) confidential and their results will be
stored for a period of 5 years). (7) As an incentive, participants will gain 3302
assignment credit for participation.
You have the right to ask questions about the research by (8) contacting
Dr. Ginsburg at 245-2526, or Ms. Becky Northcutt who manages Texas
State University research at 245-XXXX. The Instiutional Review Board has
determined that this research involves minimal risk. However, in the event that performing
the Stroop task upsets you, contact the University Counseling Center at 245- XXXX. (9)
remove harmful consequences should they occur).
At the conclusion of the study, you will be (10) debriefed and informed about the
exact questions the study examined and what anticipated results may
occur. You will be asked to describe and assess any possible risks and benefits that
occurred for you in the study. The results of the study will be made available through (1)
your instructor’s postings and (2) postings outside my office in the psychology building,
212C or (3) during class. You will be provided a copy of this form.
 To affirm your understanding of your rights as a participant in this study and your
willingness to participate you must provide your name, PLID, your instructor’s name, and
the class time and meeting day from which your participation was solicited. .
I have read and understand this consent form. I voluntarily agree to participate in the
research.

_____________________ ________________ ____________ ____________ ______

Your Name (Printed) Your Signature Your PLID# Instructor Date

___________________
Researcher Signature