Sample Informed Consent Form

We would like you to participate in the evaluation of [program name]. Your participation is important to us and will help us assess the effectiveness of the program. As a participant in [program name], we will ask you to [fill in appropriate tasks, such as complete a questionnaire].

We will keep all of your answers confidential. Your name will never be included in any reports and none of your answers will be linked to you in any way. The information that you provide will be combined with information from everyone else participating in the study.

You do not have to participate in the evaluation. Even if you agree to participate now, you may stop participating at any time or refuse to answer any question. Refusing to be part of the evaluation will not affect your participation or the services you receive in [program name].

If you have any questions about the study you may call [name and telephone number of evaluator, program manager, or community advocate].

By signing below, you confirm that this form has been explained to you and that you understand it.

Please check one:

__ Agree to participate
__ Do not agree to participate

[Include signature line for participant or parent/guardian and a line for the date.]