Informed Consent Form

[ Must be on Dal Letterhead ]

CS 4163 (Summer 2002) Prototype Evaluation Study

Principal Investigators:
[Name of a group member]
[Name of another group member]
[Name of yet another group member]
Faculty of Computer Science
Dalhousie University

   We invite you to take part in a research study at Dalhousie
University. Taking part in this study is voluntary and you may
withdraw from the study at anytime.  There will be no
repercussion from choosing not to participate in this study.  The
study is described below. This description tells you what you
will be asked to do and includes any risks or inconvenience you
might experience.

   Participating in the study may not benefit you directly but we
might learn things about the design of interfaces for [describe
activity, e.g. food recipe management] that will benefit others.
There will be minimal risks from participating in the experiment.
There is no compensation for participating in this study and you may
terminate your participation in the study at any time without
prejudice. You should discuss any questions you have about this study
with either of the principal investigators or with the people
administering the study.

   The purpose of this study is to evaluate how
[ describe appropriate some features ]
of a computer-based program can help people who
[describe anticipated user population, e.g. scholars and researchers]
to
[describe activities, e.g. take notes while reading].

   The study consists of a single session in which you will be
asked to complete some
[insert task description]
tasks using a computer program or simulated computer program and
[ filling out a short questionnaire when you are finished or whatever ].

   All personal and identifying data will be kept
confidential. No personal identifiable information will be used
in the study results.  All results will be identified by a code
which cannot be used to identify you.  This informed consent form
will be kept in a secure location under confidentiality for one
year after the end of this school term.

   If you have any difficulties with, or wish to voice concern
about, any aspect of your participation in this study, you may
contact the Human Research Ethics/Integrity Coordinator at the
Dalhousie University Office of Human Research Ethics and
Integrity for assistance. The phone number is (902)494-1462.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

`I have read the explanation about this study. I have been given
the opportunity to discuss it and my questions have been answered
to my satisfaction. I hereby consent to take part in the
study. However, I realize that my participation is voluntary and
that I am free to withdraw from the study at any time.'

Participant:					Researcher:
Name:                                      	Name:
     _________________________                       ________________________

Signature:                                 	Signature:
     _________________________                      _________________________

Date:                                       	Date:
     _________________________                      _________________________

[ end of consent form ]