Page 436 - Mike Ratner CC - WISR Complete Dissertation - v6

Appendix “B”

Consent Form

Consent Form (Emailed to Facilitators / Hosts of CC’s to give during their sessions)

As an alternative you may also mail the consent form & survey directly to the researcher.

Please complete and return to: Michael Ratner via email or U.S. mail to:
Michael D. Ratner 592 Bradford Way, Hartland Wisconsin, 53029

Name:

Phone Number:

Address:

Email Address:

I DO give permission to you to include my responses to questions during a

personal interview for the project named above. I understand my name will

not be used in the dissertation or any subsequent reports.

I DO NOT give permission to be interviewed in the study named above.

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