Peltier[Improper File Name]99
Single Subject Design Weight Loss Project
Consent Form
Assignment # 5
You are invited to participate in a study about weight loss. My name is Gertrude Peltier, but I prefer to be called Trudy. I’m a graduate student at Michigan State University in the Social Work Department. This project is part of my work as a graduate student and this research project will be part of my semester grade for a class entitled Research Methods for Social Workers. I hope to learn how evening eating affects weight loss. You were selected as a possible participant in this study because you have shown interest in learning what’s the best way to lose weight and stay healthy. You will be the only subject in this study.
If you decide to participate, I, Trudy Peltier, will weigh you daily in the morning for 14 days during the baseline phase. There will be no restrictions regarding evening eating during this phase. During the intervention phase which will last 14 days, you will stop eating after 7:00 PM on a daily basis. You will continue to be weighed in the morning on a daily basis. During the withdrawal phase there will be no restrictions for 14 days regarding evening eating and you will continue to be weighed daily in the morning. You may suffer the discomfort of hunger, loss of energy, or irritability. During the intervention phase it may be inconvenient for you to fit your dinner into your daily work schedule before 7:00 PM and to eat out with family and friends if they prefer to eat later in the evening than 7:00 PM. It’s also possible that you may not lose weight and could even gain weight. You may benefit from this program by losing weight, increasing energy, and fitness. You also may feel better and improve your physical health.
There is any number of weight loss programs that could provide an alternative program to assist you with your endeavor towards weight loss. Please consult your family doctor for appropriate referrals.
Any information obtained in connection with this study and that can be identified with you will remain confidential. It will be disclosed only with your permission.
Your decision whether or not to participate will not affect your future relations with Michigan State University. If you decide to participate, you are free to discontinue participation at any time.
You’re making a decision regarding whether or not you want to participate. Your signature indicates that you have read the information provided above and that you have decided to participate. You may withdraw at any time after signing this consent form should you choose not to participate in this study.
If you have any questions, please contact me by phone. My home phone number is 906-293-5234 and my office phone is 906-293-3284. My faculty advisor is Professor Timothy Stocks. He’s also available for consultation at 517-432-4092. [SINCE YOU ARE THE RESEARCHER AND I AM NOT, I WOULD NOT BE ABLE TO GIVE THE PARTICIPANT MUCH IN THE WAY OF USEFUL INFORMATION.]
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Consent Form
After signing the consent form, a copy will be provided to you by me, Trudy Peltier, for your future reference.
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Signature of Participant Date
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Signature of Witness (When Appropriate) Date
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Signature of Investigator Date