Cultic Studies Journal, Vol. 12, No. 2, 1995, page 15
~~~~~~~
Exhibit 2
Sample Consent Form
Podunk University
Department of Psychology
Somewhere, USA
Consent to Be a Research Participant
I understand that the purpose of this research is to analyze some of my experiences as
a member of the Church of the Sacred Cow in order to make sense of them and to help
other former members.
I understand that if at any time I wish to terminate the interview, I simply need tell the
interviewer.
I understand that the information provided by me is confidential. Please check one or
more of the following statements:
____I prefer that my real name not be used in published reports.
____I prefer that my real name be used in published reports.
____I would like to read and edit my reports before publication.
I understand that this interview is being tape recorded and that the tape will be in the
custody of the research team. Please check one:
____I prefer that the tape not be played by other than the research team.
____I prefer that the tape be played before interested persons.
I understand that I may be interviewed ___times, that each interview will last about
an hour, that the purpose is to gather information for research, not to provide
counseling. If I have any questions or problems about or as a result of this interview, I
can call one of the research team.
Signature____________________________ Date_____________
Thank you very much for your collaboration in this project.
A.B.C. Dee, Ph.D., Chief Investigator
~~~~~~~
Exhibit 3
Former Cult Member’s Personal Information Form
We would like to have some information about you on record. In order to save time, we
would appreciate your completing this personal information form. Your answers are, of
course, confidential, and will be used for research purposes only. Please complete every
item if for any reason you prefer not to reply to a question, please write “NA.”
1. Date _______________
2. Name _________________________________________
3. Mailing address __________________________________
4. Home telephone _________________
5. Gender _________________
6. Age ___________________
7. Name of group ___________________________________
~~~~~~~
Exhibit 2
Sample Consent Form
Podunk University
Department of Psychology
Somewhere, USA
Consent to Be a Research Participant
I understand that the purpose of this research is to analyze some of my experiences as
a member of the Church of the Sacred Cow in order to make sense of them and to help
other former members.
I understand that if at any time I wish to terminate the interview, I simply need tell the
interviewer.
I understand that the information provided by me is confidential. Please check one or
more of the following statements:
____I prefer that my real name not be used in published reports.
____I prefer that my real name be used in published reports.
____I would like to read and edit my reports before publication.
I understand that this interview is being tape recorded and that the tape will be in the
custody of the research team. Please check one:
____I prefer that the tape not be played by other than the research team.
____I prefer that the tape be played before interested persons.
I understand that I may be interviewed ___times, that each interview will last about
an hour, that the purpose is to gather information for research, not to provide
counseling. If I have any questions or problems about or as a result of this interview, I
can call one of the research team.
Signature____________________________ Date_____________
Thank you very much for your collaboration in this project.
A.B.C. Dee, Ph.D., Chief Investigator
~~~~~~~
Exhibit 3
Former Cult Member’s Personal Information Form
We would like to have some information about you on record. In order to save time, we
would appreciate your completing this personal information form. Your answers are, of
course, confidential, and will be used for research purposes only. Please complete every
item if for any reason you prefer not to reply to a question, please write “NA.”
1. Date _______________
2. Name _________________________________________
3. Mailing address __________________________________
4. Home telephone _________________
5. Gender _________________
6. Age ___________________
7. Name of group ___________________________________
