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Please circle your answers:
1) Will the human subjects be informed of the nature of their involvement in the collection
of data and of features of the research that reasonably might be expected to influence
willingness to participate? Yes No
2) Will the human subjects be told that they can discontinue their participation at any time? Yes No
3) Will the human subjects in your study be aware that they are the targets of research? Yes No
4) If the subjects are underage, will their guardians be asked to sign the consent form? Yes No N/A
5) Is the confidentiality of the human subject’s identity positively ensured? Yes No
6) In cases where there is a possibility that the human subject’s identity can be deduced by Yes No
someone other than the researcher, is the subject’s right to withdraw his/her data
respected?
7) Will the researcher fulfil all the promises made to the human subjects including providing Yes No
the summary of the findings upon request?
8) Will all necessary measures be taken to protect the physical safety of Yes No
the human subjects from dangers such as faulty electrical equipment, poor
grounding, lack of oxygen, falls, traffic & industrial accidents, possibility
of hearing or vision loss etc.?
9) Will the human subject be debriefed (told the true nature of the study) after Yes No
the data has been collected?
10) In cases in which the human subject is dissatisfied or a complaint about the researcher or Yes No
procedure, will the researcher explain to the human subject that he or she may express
this complaint to the Subject Coordinator?
11) Does the study involve concealment from and/or deception of the human subject? Yes No
12) Will deception be used in order to obtain agreement to participate? Yes No
13) Will the study involve human subjects who are legally or otherwise not in a position to
give their valid consent to participate such as children, prison inmates, mental patients? Yes No
14) Will information on your human subjects be obtained from third parties? Yes No
15) Will any coercion be exerted upon subjects to participate? Yes No
16) Will the study involve physical stress to the human subjects such as might Yes No
result from heat, noise, electric shock, pain, sleep loss, deprivation of
food and drink, drugs, alcohol?
17) Will the study cause any mental discomfort to the human subjects such as fear, Yes No
anxiety, loss of self-esteem, shame, guilt, embarrassment etc.?
18) Could publication of the research results possibly interfere with strict confidentiality? Yes No
19) Could publication of the research results possibly harm the human subject –
either directly or through identification with his/her membership group? Yes No
20) Are there other aspects of the study that may interfere with the protection of the Yes No
well-being of the human subjects?
If you have selected NO for any of the questions 1 to 10 and/or you have selected YES for any of the questions 11 o 20, please provide comments to clarify your choice (use additional pages if necessary).
