Rogat+-+Consent+form+-+country+club

Institutional Review Board Rensselaer Polytechnic Institute

__Informed Consent Form__ (Student Researcher)

I understand that Michelle Rogat is an undergraduate student who wishes to utilize information and resources the Country Club of XXXX can provide as part of her senior thesis research on the implementation of sustainability projects into businesses and establishments, under the guidance of Professor Kim Fortun in the Science and Technology Studies Department at Rensselaer Polytechnic Institute. I understand that she will take all possible measures and make her best effort to guarantee the club and it’s members every possible protection wanted, including:

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 * 1)  Interviews are to be done without taking any identifiable information, unless given consent by the interviewee.
 * 1)  Interviews are only to be recorded through hand-written or typed notes, not by audio recording unless given consent otherwise.
 * 1)  Interviewees may decline to answer any questions or end the interview process at any point they feel.
 * 1)  Interviewees must be notified before hand if they are going to be quoted, and they must approve it first.
 * 1)  The Country Club of Troy will be given a copy of all interview notes and recordings of the members and employees.
 * 1)  Any research or interviewing shall be done on her own time, not when she is actually scheduled to work at the country club serving.
 * 1)  Any research may not interrupt the flow of business at any time.
 * 1)  Everyone involved in the research will have to abide by any of the club’s privacy requests.

Based on reading this the Country Club of Troy has decided to: ___Grant her permission for research at the club and would like a meeting to discuss details ___Grant her permission for research at the club under certain conditions listed below or attached ___Request further information about the research before deciding further ___Deny her permission for research at the club for reasons listed below ___Other:

Name(Printed) Position Signature Date