CORINTE -Autorisations et consentement éclairé

Accueil > Recueil > Autorisation > Demande d'autorisation

Exemples de demandes d'autorisation

1) Exemple de formulaire type de demande d'autorisation mis au point au laboratoire ICAR, élaboré en coordination avec des juristes du projet PSI Patrimoine

[papier avec en-tête officiel]

Autorisation
pour l'enregistrement audio/video
et l'exploitation des données enregistrées

Présentation de l'enquête

[Peut se présenter sous forme de brochure séparée laissée aux enquêtés]

Préciser l'institution d'où émane la recherche, la personne qui dirige / qui est responsable du projet, les chercheurs concernés sur le terrain.

Préciser le thème général du projet, le type de corpus qui est recueilli de manière générale, le type d'enregistrement qui est recueilli auprès de ces informateurs en particulier, les traitements et utilisation prévus.

Souligner les apports du projet, valoriser la collaboration de l'informateur, expliciter les bénéfices éventuels qu'il peut en tirer et les risques éventuels qu'il peut courir.]

Ces recherches ne sont possibles que grâce au consentement des personnes qui acceptent d'être enregistrées. Nous vous demandons par conséquent votre autorisation à procéder aux enregistrements.

Autorisation (biffer les paragraphes qui ne conviennent pas)

Je soussigné(e) _______________________________________

- autorise par la présente NN et NN à enregistrer en audio/vidéo le [préciser le type d'événement enregistré].

- autorise l'utilisation de ces données, sous leur forme enregistrée aussi bien que sous leur forme transcrite et anonymisée (cf. infra) :

a) à des fins de recherche scientifique (mémoires ou thèses, articles scientifiques, exposés à des congrès, séminaires) ;

b) à des fins d'enseignement universitaire (cours et séminaires données à des étudiants avancés, à partir du niveau maîtrise, en sciences du langage et en sciences sociales) ;

c) pour une diffusion large dans la communauté des chercheurs, sous la forme d'éventuels échanges et prêts de corpus à des chercheurs, moyennant la signature d'une convention de recherche ;

d) pour une diffusion sur un site Internet dédié à la recherche.

- prends acte que pour toutes ces utilisations scientifiques les données ainsi enregistrées seront anonymisées : ceci signifie

a) que les transcriptions de ces données utiliseront des pseudonymes et remplaceront toute information pouvant porter à l'identification des participants ;

b) que les bandes audio qui seront présentées à des conférences ou des cours (généralement sous forme de très courts extraits ne dépassant pas la minute) seront « bipées » lors de la mention d'un nom, d'une adresse ou d'un numéro de téléphone identifiables (qui seront donc remplacés par un « bruit » qui les effacera) ;

c) en revanche, pour des raisons techniques, le projet ne peut pas s'engager à anonymiser les images vidéo mais s'engage à ne pas diffuser d'extraits compromettant les personnes filmées.

- souhaite que la contrainte supplémentaire suivante soit respectée :.................................................................................................................

Lieu et date : ____________________

Signature : _____________________________________________

[Prévoir un double ou un autre document qui sera laissé à la personne, comportant une adresse de contact et éventuellement une adresse internet où consulter les résultats publiés du projet]

2) Exemple de demande d'autorisation pratiquée par la Talkbank

(source : http://talkbank.org/share/consent.html)

Part I: Explanation of Informed Consent

We are asking you to be a subject in a research study. If you agree to participate in this study, we would like to ask you to sign this informed consent document. Informed consent is a written agreement that you sign indicating your willingness to participate in this research. This document will tell you about the purpose, risks, and benefits of this research study. You should consent only after you have received all the necessary information and have had enough time to decide whether you wish to participate. Your signature on this form is voluntary and does not waive any of your legal rights or make any institutions or persons involved in this research any less responsible for your well being.

Part II: Explanation of Current Study

Why have I been asked to be a part of this study?

(Sample Text: We are asking your permission to videotape you, because we are hoping that you will take part in a communicative interaction that we hope to study.)

Who is responsible for the data collected in this study?

(Name and Address of Project Director.)

Why is this study being done?

(The purpose of this study is to Statement of Project Goals.)

What is involved in this study?

(Sample Text: We will videotape your participation in the (Description of the Type of Interaction Being Filmed). We will try to avoid interfering with the activity during filming. However, you will always be aware when videotaping is taking place. In some circumstances, you maybe contacted after the activity and asked to help us make sense of the activity captured on the tape.)

Who will look at the resulting data?

These data are only available for research purposes. All uses for commercial or other non-research purposes are prohibited. Researchers using these data must subscribe to a Code of Ethics that requires them to respect the views of all participants. Segments of the tape with accompanying transcriptions may be presented in the context of scholarly publications, academic symposia, university classes, and professional training activities. Data will be made available to researchers through CD-ROM or web distribution by password.

What level of access am I permitting?

(The researcher should choose one of these three levels to present here and below):

1.        I am allowing full access to these data to researchers who subscribe to the TalkBank Code of Ethics.

2.        I am allowing access to these data to researchers who subscribe to the TalkBank Code of Ethics and who have received a special password allowing them to use these data.

3.        I am allowing access to these data to researchers who subscribe to the TalkBank Code of Ethics and who are sent the data on CD-ROM.

How long will I be in this study?

Your consent extends only for the duration of the following activity: ________________. The video acquired (Specify activity and dates) will be preserved indefinitely unless you request otherwise (see risks). Even after the interaction has been filmed, you have the right to revoke your agreement to participate in this study and to remove your data from inclusion.

What are the risks of this study?

Because of the nature of the data being gathered (i.e., video and audio recordings), it may not be possible to conceal your identity as a participant. There is a potential risk that people known or unknown to you will formulate negative opinions of you or your behavior on the basis of their viewing of these data. We have three safeguards against this:

1.        Researchers using these data must subscribe to a Code of Ethics that requires them to respect your views, as well as those of all other participants. Any written or verbal public criticism of individuals or groups must first be reviewed by a committee of scholars. If you wish, you can will be provided with a copy of this scholarly Code of Ethics.

2.        You can request that videotaping be stopped at any point during the activity, thereby preventing a video record from ever being produced.

3.        You may review the recording. If you wish, you may file a request with the Principal Investigator to have particular segments containing your likeness deleted or erased.

4.        As discussed in the section on confidentiality below, all additional data, apart from the videotape, will be confidential.

Are there benefits to taking part in this study?

There are no direct benefits to you personally for participating in this study. The primary benefits from this work are for the advancement of scientific understanding of communication processes. The availability of these data may lead to improvements in Field of Study of which you or others may be a direct beneficiary. If you are interested in these scientific outcomes, arrangements can be made with the Principal Investigator to acquire digitized files of the interaction, along with transcripts and analyses, as they become available.

Will I receive any payment or other monetary benefits?

You will receive no payment for being videotaped. This data will not be used for commercial purposes. Therefore, you should not expect any royalties or payments in the future.

What other options are there?

You can choose not to participate in this study.

What about confidentiality?

The nature of the data being gathered precludes concealing your identity as a participant. Any researcher who happens to know you personally would be able to identify you from the videotape or the audiotape. If this occurs, our Code of Ethics requires that this researchers refrain from making further use of these data. In addition,, we will keep any additional information that we have about you confidential through the use of pseudonyms. These data will not be made available for any purposes outside of research activities.

What are the costs?

There are no costs to you for participating in this study.

What are my rights as a participant?

Taking part in this study is voluntary. You may choose to not take part or subsequently cease participation at any time. Leaving this study will not result in any penalty or loss of benefits to which you are entitled.

Part III: Informed Consent Approval

Project Title: Project Title

Conducted By: Project Director

I have read the above explanations and I agree to participate in the research study conducted by (Project Director). I understand that the proposed research has been reviewed by the University's Institutional Review Board and that, to the best of their ability, they have determined that, given my informed consent, the filming and analysis of these conversational interactions involve no procedures or requirements which may be found morally or ethically objectionable. They have also determined that the benefits from this research outweigh any potential risks. If, however, at any time I wish to terminate my participation in this study I have the rights to do so without penalty, even after the data have been collected. I also have the right to review the audio and video data and can request that specific segments be omitted, if they contain material that might embarass me.

If I have any question about this study, I realize that I am encouraged to ask them now or at anytime during the study by contacting:

(Project Director's name, building, office number phone, fax, and email. Include possible alternate contacts too.)

I realize that I may report any objections to this study, either orally or in writing, to:

(Director of the University Office of Human Subjects Review.)

I agree to allow the following level of research access to these data from the conversational interaction in which I have participated.

(Insert materials from the list of access levels above.)

I understand that, in signing this consent form, I give Project Director, and his associates, permission to present this work in written and oral form, without further permission from me.

Signed, Dated

3) Exemple de demande d'autorisation de Susan Ervin-Tripp, Univ. de Californie, Berkeley

Researcher name_______________________

LETTER OF CONSENT

PHOTOGRAPHIC, AUDIO, AND/OR VIDEO RECORDS RELEASE CONSENT FORM

As part of this project we have made a photographic, audio, and/or video recording of you while you participated in the research. We would like you to indicate below what uses of these records you are willing to consent to. This is completely up to you. We will only use the records in ways that you agree to. In any use of these records, names will not be identified.

1. The records can be studied by the research team for use in the research project.

Photo __________ Audio __________ Video __________

[Please use initials]

2. The records can be shown to subjects in other experiments.

Photo __________ Audio __________ Video __________

[Please use initials]

3. The records can be used for scientific publications.

Photo __________ Audio __________ Video __________

[Please use initials]

4. The written transcript can be kept in an archive for other researchers.

Photo __________ Audio __________ Video __________

[Please use initials]

5. The records can be used by other researchers.

Photo __________ Audio __________ Video __________

[Please use initials]

6. The records can be shown at meetings of scientists

interested in the study of ___________

Photo __________ Audio __________ Video __________

[Please use initials]

7. The records can be shown in classrooms to students.

Photo __________ Audio __________ Video __________

[Please use initials]

8. The records can be shown in public presentations to nonscientific groups.

Photo __________ Audio __________ Video __________

[Please use initials]

9. The records can be used on television and radio.

Photo __________ Audio __________ Video __________

[Please use initials]

I have read the above description and give my consent for the use of the records as indicated above.

Date _________________

Signature _________________________

Signature of Guardian, if Applicable ____________________________

Native language(s)_________________________________________

Where native language learned (city or region)_____________________

Languages used on the tape____________________________________

Where language(s) used on tape were learned ______________________

Age at which each language used on tape was learned __________________

Education ________________Occupation _______________________

Name _______________________________ Age _______ Sex __

Pour citer cette page : groupe ICOR 2006, titre de la page, site CORINTE
http://icar.cnrs.fr/projets/corinte/