(Experimenter(s) should type information as required)

Experiment Number (assigned by Psychology Department):

Name(s) of Experimenter(s):
 

Purpose of Study:
 
 
 
 
 
 
 
 
 
 

Procedures Required of Subject:
 
 
 
 
 
 
 
 
 

Risks to Subject:

Benefits to Subject:
 

I have read and understood the description above.  I understand that I may withdraw my participation as a subject at any time during the study, without penalty.  I also understand that the results of my participation will be confidential and that if the results are reported or published, my anonymity will be preserved.   On this basis I agree to serve as a participant in this study. ____________________________________________________________________ Print Name Here                                 Signature                        Date