Neftaly Ethics and Consent Declaration Form (Neftaly Template #ECD01)

Neftaly Ethics and Consent Declaration Form

Template Code: Neftaly Template #ECD01
Issued by: Neftaly Research Ethics Office
Required For: All Neftaly research involving human participants, personal data, or community-based fieldwork

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Neftaly Section 1: Research Project Information

Field	Description
Project Title	Full title of the research or case study
Project Code	Internal Neftaly tracking ID (if applicable)
Lead Researcher	Full name and position
Research Team Members	Names of co-researchers, assistants, or collaborators
Associated Neftaly Unit/Program	e.g., Economic Impact Studies, Social Inclusion Program
Date of Submission	DD/MM/YYYY

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Neftaly Section 2: Ethics Declaration by Researcher

Please confirm the following statements by ticking the boxes:

Declaration Statement	Yes / No / N/A
I confirm that this study adheres to Neftaly’s Code of Ethics for research.	☐ Yes ☐ No
I confirm that informed consent will be obtained from all participants.	☐ Yes ☐ No
I confirm that participants can opt out at any stage without consequence.	☐ Yes ☐ No
I confirm that no personal data will be collected without consent.	☐ Yes ☐ No
I confirm that data will be stored securely and anonymously where applicable.	☐ Yes ☐ No
I confirm that risks to participants have been assessed and minimized.	☐ Yes ☐ No
I confirm that local cultural, legal, and community standards have been considered.	☐ Yes ☐ No

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Neftaly Section 3: Participant Consent Process

Item	Description
Consent Method	☐ Written Consent ☐ Verbal Consent ☐ Digital Consent
Language Used	Languages in which consent will be obtained
Consent Form Attached	☐ Yes ☐ No
Are minors or vulnerable populations involved?	☐ Yes ☐ No

If yes, include guardian consent protocols and additional safeguards.

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Neftaly Section 4: Risk and Mitigation Overview

Risk Identified	Mitigation Strategy
e.g., Disclosure of sensitive personal data	Anonymization and secure data handling
e.g., Participant distress during interviews	Use of trained facilitators and opt-out options

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Neftaly Section 5: Researcher Declaration and Signature

“I, the undersigned, confirm that I understand and accept my ethical responsibilities in the conduct of this research. I will adhere to Neftaly’s ethical guidelines and ensure the safety, rights, and dignity of all research participants.”

Name	Signature	Date
Lead Researcher
Co-Researcher(s) (if applicable)

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Neftaly Section 6: Neftaly Ethics Committee Use Only

Review Stage	Status	Reviewed By	Date
Ethics Review	☐ Approved ☐ Revisions Needed
Comments

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📝 Submission Instructions

• Submit this form along with your Neftaly Research Planning Worksheet (#RPW01) and Consent Form samples to:
  ethics@saypro.org or via the Neftaly Research Compliance Portal.
• Use subject line: [Ethics Declaration – Template #ECD01 – Project Title]

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✅ Notes

• This form must be submitted before any fieldwork or data collection begins.
• Projects involving external partners may require additional clearance from local/national ethics boards.

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