I, _______________________________________ agree to participate in an interview with ______________________________________, an Edgewood College nursing student.  I understand that the purpose of the interview is to explore my cultural heritage and to help the student understand how my life experiences, beliefs and practices affect my health care needs.

The student has my permission to audiotape this discussion.  The student has explained that this tape will be shared with his/her instructor and that my right to privacy and confidentiality will be protected in all instances.

The student has further explained that if I have questions or concerns regarding the visit, its purpose or his/her conduct during the visit that I may call her course instructor.  He/she has provided me with that individual’s name and phone number.
 

Participant ________________________________________________  Date _____________

Telephone Number _________________________________________

Edgewood Student  _________________________________________
 
 
 

 © 2000 Jane E. Lucht - N210 Foundations of Professional Nursing