Informed Consent Form

CS 4163 (Summer 2001) 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 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 some features of a computer-based
program can help people who
[describe anticipated user population, e.g. like to cook using recipes]
to
[describe activities, e.g. cook using recipes and effectively maintain a
shopping list].

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.

All personal and identifying data will be kept confidential. No personal
identifiable information will be used in the study results.

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:
     _________________________                      _________________________