Informed Consent Form

City ______________________________________

State,County ______________________________

Date ______________________________________

1. I hereby agree to participate in an interview in connection with the oral history project known as _____________________________________.I understand that I will be asked about _____________________________________

2. The interview will be audiotaped. In the interview I may be identified by name, subject to my consent. I may also be identified by name in any transcript (whether verbatim or edited) of such interview, subject to my consent. If I choose to remain anonymous, I know that the tape(s) of my interview will be closed to use, and my name will not appear in the transcript or reference to any material contained in the interview. I know that in the case of choosing to remain anonymous, my interview ill only be identified by an internal tracking number.

3. I understand that the interview will take approximately two hours and that I can withdraw from the project without prejudice prior to the execution and delivery of a deed of gift, a form of which is attached hereto. In the event that I withdraw from the interview, any tape made of the interview will be either given to me or destroyed, and no transcript will be made of the interview. I understand that a photograph of me will be taken or borrowed for duplication, and that if I withdraw from the project, the photograph will be given to me.

4. Subject to the provisions of paragraph five below, I understand that, upon completion of the interview, the tape and content of the interview belong to [name of interviewer], and that the information in the interview can be used by [interviewer] in any manner it will determine, including, but not limited to, use by researchers in presentations and publications.

5. [Interviewer] agrees that: (i) it will not use or exercise any of its rights to the information in the interview prior to the signing of the deed of gift; (ii) the deed of gift will be submitted to me for my signature at completion of the interview; and (iii) restrictions on the use of the interview can be placed in the deed of gift and will be accepted as amending [interviewer's] rights to the content of the interview. I understand that I have the right to review the tape or transcript of the interview before I sign the deed of gift.

6. Any restrictions as to use of portions of the interview indicated by me will be edited out of the final copy of the transcript.

7. I understand that at the conclusion of this particular study and upon signing the deed of gift, the tape, photograph, and one copy of the transcript will be kept in the [location of archive, etc].

8. If I have questions about the research project or procedures, I know I can contact _________________.

If I feel I have not been treated according to the descriptions in this form, or that my rights as a participant in research have been violated during the course of this project, I know I can contact [the office or the Human Subjects Committee, etc.].

____ I agree to be identified by name in any transcript or reference to any information contained in this interview.

____ I wish to remain anonymous in any transcript or reference to any information contained in this interview. I wish to have the tape(s) containing my interview closed to use. I wish to have my transcript only identified by an internal tracking number.

Interviewer signature_____________________________________

Interviewee signature_____________________________________

Address _____________________________________

_____________________________________

_____________________________________

Phone number: ___________________________

consent date __/__/__