Records & Authorization
Survey and Data Collection Consent
Consent form for survey participation and data collection covering data use, anonymity, and withdrawal rights. Single signer (respondent).
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# Survey and Data Collection Consent **Effective Date:** ___________ This Survey and Data Collection Consent ("Consent" or "Agreement") is made by: **Conducting Organization:** ___________ ("Organization") **Respondent:** ___________ ("Respondent") ## 1. Survey/Study Information **Survey Title:** ___________ **Purpose:** ___________ **Principal Investigator/Contact:** ___________ **Contact Email:** ___________ **Contact Phone:** ___________ ## 2. Participation Details **Survey Type:** ___________ **Estimated Duration:** ___________ **Number of Sessions (if multi-session):** ___________ **Participation is:** ___________ ## 3. Data Collected The following types of data may be collected: **Data Categories:** ___________ **Specific Data Points:** ___________
Fields (37)
effective date
date 路 required
organization name
text 路 required
respondent name
text 路 required
survey title
text 路 required
survey purpose
textarea 路 required
investigator name
text 路 required
investigator email
text 路 required
investigator phone
text
survey type
select 路 required
duration
select 路 required
sessions
select 路 required
voluntary
select 路 required
data categories
select 路 required
specific data
textarea 路 required
recording
select 路 required
data use
select 路 required
use details
textarea
data sharing
select 路 required
third parties
textarea
anonymity
select 路 required
confidentiality measures
select 路 required
risks
select 路 required
benefits
select 路 required
compensation
select 路 required
compensation details
textarea
early withdrawal comp
select 路 required
withdrawal data
select 路 required
withdrawal contact
text 路 required
retention period
select 路 required
destruction method
select 路 required
vulnerable pop
select 路 required
irb review
select 路 required
irb number
text
ethics contact
text 路 required
ethics email
text 路 required
governing state
select 路 required
respondent signer name
text 路 required
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