Vancouver Island University

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Vancouver Island University

Department of Anthropology

Sample: Informed Consent Form for Surveys or Questionnaires

Preamble: Information marked [xxx] is for your information and should not be included in your form. You must submit your questions to your supervisor for a departmental ethics review. Instead of having a full consent form, you are required to provide information regarding the project and informed consent at the top of your survey.

Fast Food & You [Title]

We are Vancouver Island University students in an upper level anthropology course, ANTH 324 - Food and Culture. This research project is designed to examine the popularity of fast food and the factors that influence an individual’s choice in consuming fast food, as represented by such companies as McDonald’s and Burger King. [Purpose]

Your participation is completely voluntary; you can terminate the survey at anytime without explanation. The survey will take about 15 minutes. By completing this survey, you are giving consent. [Informed and voluntary consent]

Please do NOT put your name on this survey. Your answers will be kept in total confidence. [Confidentiality]

1 I am a student q staff member q faculty member q

2 If a student, how many courses are you taking this semester?

q 1 q 4

q 2 q 5

q 3 q >5

3 How old are you?

q <20 q 40-49

q 20-29 q 50-59

q 30-39 q 60 or over

4 What is your sex? q Female q Male

5 Do you have access to kitchen facilities? q Yes q No

6 Do you eat fast food?

q Yes q No, thank you for your participation.

7 How often do you eat fast food per week?

q >5 q 4-5 q 2-3 q 1-0

8 Which is your favourite fast food establishment?

q A&W q Burger King

q Dairy Queen q McDonald’s

q Other ___________________

9 What factors influence your decision to eat fast food? (Answer as many as apply)

q taste q location

q good value (cost) q fast (time)

q Other ____________________

10. Of the factors identified (Q.9), which is the most important?

q taste q location

q good value (cost) q fast (time)

q Other ____________________

Thank you for your time and participation in completing this survey.


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