HOW TO USE THIS CONSENT FORM:

This document is the standard REC-approved template to assist you with designing a written
informed consent form. You may adapt the template as you see fit, but remember that the
document must address the participant directly, have some information about each heading and
include the SU logo at the top. Please write in SIMPLE, NON-TECHNICAL language.

The text written in [RED] is for guidance only and should be removed before finalising the
document. Also, this information box should be deleted before the document is finalised.

STELLENBOSCH UNIVERSITY
CONSENT TO PARTICIPATE IN RESEARCH

You are invited to take part in a study conducted by [insert names of all researchers involved],
from the [insert your SU department affiliation] at Stellenbosch University. You were approached
as a possible participant because [explain why the person is being asked to participate].

1. PURPOSE OF THE STUDY

[Give a short summary of what the study is about in simple, non-technical language.
Remember the consent form is for the participant – please do not copy-and-paste from your
research proposal]

2. WHAT WILL BE ASKED OF ME?

If you agree to take part in this study, you will be asked to [describe in simple, non-technical
language all the activities the participant will be involved in for this study or what
they will be asked to do. Scientific terms should be defined and explained. Some things you
may want to mention here are: the length of time estimated for participation in each activity, the
frequency of activities, the location where activities will be done, etc. ]

3. POSSIBLE RISKS AND DISCOMFORTS

[Mention any foreseeable risks, discomforts, inconveniences, and discuss how you
will address or manage these risks to protect the participant (e.g. referral for
counselling or therapy, etc.). ]

4. POSSIBLE BENEFITS TO PARTICIPANTS AND/OR TO THE SOCIETY

[State the direct benefits to participants that could be expected from their participation in the
study. If the participants will not benefit directly, clearly state this fact. Also, mention
(realistically) the potential benefits, if any, to society expected from this study.]

5. PAYMENT FOR PARTICIPATION

Written consent template. REC: Humanities (Stellenbosch University) 2017

[State whether the participant will receive payment or whether the participant will be
compensated for any expenses paid to take part in the study (e.g. compensated for transport
costs, entry into lucky draws). If not, state so clearly. If participants will receive payment, state
the amount, state when payment can be expected, and describe the proration schedule should
the participant decide to withdraw.]

6. PROTECTION OF YOUR INFORMATION, CONFIDENTIALITY AND IDENTITY

Any information you share with me during this study and that could possibly identify you as a
participant will be protected. This will be done by [describe the measures you will take to ensure
confidentiality and/or anonymity, where and how data will be stored, who will have access to it,
will participants or organisations be identified in the final research report?, etc.] .

[If the information will be released to or shared with any other party/agency for any reason,
please mention this here and identify the person/agency to whom the information will be
furnished, the nature of the information, and the purpose of this disclosure. State whether the
participant has the option to opt-out of their information being shared. State whether the
information collected for this study will be used for future publications and/or used for other
purpose in the future].

[If activities will be audio-recorded, photographed or videotaped, mention this here and state
whether the participants will have the opportunity to review/edit the tapes, who will have access
to these recordings, if they will be used for educational purposes, and when they will be erased. ]

[If you plan on publishing the results of the study describe how confidentiality and/or anonymity
will be maintained in the publication]

7. PARTICIPATION AND WITHDRAWAL

You can choose whether to be in this study or not. If you agree to take part in this study, you
may withdraw at any time without any consequence. You may also refuse to answer any
questions you don’t want to answer and still remain in the study. The researcher may withdraw
you from this study if [describe the anticipated circumstances under which participation may be
terminated without regard to the participant's consent.]

8. RESEARCHERS’ CONTACT INFORMATION

If you have any questions or concerns about this study, please feel free to contact [Researcher’s
name and surname] at [researcher contact information], and/or the supervisor [Supervisor’s
name and surname] at [Supervisor’s contact information].

9. RIGHTS OF RESEARCH PARTICIPANTS

You may withdraw your consent at any time and discontinue participation without penalty. You
are not waiving any legal claims, rights or remedies because of your participation in this research
study. If you have questions regarding your rights as a research participant, contact Ms Maléne
Fouché [mfouche@sun.ac.za; 021 808 4622] at the Division for Research Development.

Written consent template. REC: Humanities (Stellenbosch University) 2017

 DECLARATION OF CONSENT BY THE PARTICIPANT

As the participant I confirm that:

 I have read the above information and it is written in a language that I am comfortable
with.
 I have had a chance to ask questions and all my questions have been answered.
 All issues related to privacy, and the confidentiality and use of the information I provide,
have been explained.

By signing below, I ______________________________ (name of participant) agree to take part

in this research study, as conducted by _____ (name of principal investigator).

_______________________________________ _____________________
Signature of Participant Date

DECLARATION BY THE PRINCIPAL INVESTIGATOR

As the principal investigator, I hereby declare that the information contained in this document
has been thoroughly explained to the participant. I also declare that the participant has been
encouraged (and has been given ample time) to ask any questions. In addition I would like to
select the following option:

The conversation with the participant was conducted in a language in which the
participant is fluent.

The conversation with the participant was conducted with the assistance of a translator
(who has signed a non-disclosure agreement), and this “Consent Form” is available to the
participant in a language in which the participant is fluent.

________________________________________ _____________________

Signature of Principal Investigator Date

Written consent template. REC: Humanities (Stellenbosch University) 2017