Informed Consent

I, ____________________________, as a legally nominated representative of ______________________________________, have been fully informed of the project (insert the objectives of the project; the partners and nature of partnership, funding, outcomes and benefi ts; what the recipient / researcher expects from the provider, including any targets that may be envisaged; assurance of authenticity; etc.). __________________________________________________________________ ________________________________________________________________ __________________________________________________________________ ______________________________________________________________

Commitment of the Recipient Include the following information:

1. The research process emphasizing what the recipient will do in and/or for the community

2. Key principles that will be observed such as:

a) Confidentiality;
b) Respect and cultural sensitivity;
c) Communication;
d) Empowerment;
e) Equity; and
f) Indigenous guardianship.

3. Conditions Associated with the Project Include explanations of all conditions that may affect the Provider such as:

a) Life of the agreement;
b) Withdrawal;
c) Amendment; and
d) Renegotiation.

4. Commitment of Representative of the Provider

The representative of the Provider must be made aware of his / her role and rights in the project. Commitment should be obtained on:

a) Willingness to represent provider (community);
b) Legal nomination of the representative;
c) Freedom to withdraw from the project (in person) at any time without affecting the project; and
d) Freedom to withdraw the community participation from the project, without jeopardizing future projects.

Signature of TK holder / practitioner: _______________________________ Date: _____/______/20____

Signature of TK recorder who obtained informed consent: _______________ Date: _____/______/20____

Signature of witness: _____________________________________________
Date: _____/______/20____

Append documents mentioned in the agreement as appropriate.

Project Information

(Note: Care must be taken to avoid the indiscriminate use of technical jargon and, where appropriate, the document should be translated into local languages)

Title of Project: __________________________________________________________________ Synopsis of the Project (Clearly summarize what the project is about, the objectives, the partners, the outcome, benefits etc.)

Contribution of the Provider

Explain what the Recipient / Researcher expects from the Provider, including any targets that may be envisaged and assurance of authenticity.

Rights of Project Partners Include explanations on:

a) Withdrawal;
b) Amendment; and
c) Renegotiation.

Additional Information

Invite the Provider to feel free to ask any questions about the project.

Contacts: Include contact details of key project personnel


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