Community-Based Participatory Research Ethics Form

1. Project Information

Project Title Project Lead(s) Institution/Organization Contact Email Project Start Date Project End Date

2. Community Partners

List all community organizations and individuals involved

3. Purpose and Goals

Describe the project purpose and goals

4. Community Participation

Describe the roles of community partners in the research process

5. Consent and Confidentiality

Describe how you will obtain informed consent from participants Describe measures taken to ensure confidentiality and privacy

6. Risks and Benefits

Potential risks to participants Potential benefits for participants and the community

7. Data Management

Describe how data will be collected, stored, and shared

8. Community Dissemination Plan

How will you share results/findings with the community?

9. Signatures

Research Lead Name Date Community Partner Name Date