Consent Form for Online Surveys

You are invited to participate in a web-based online survey on Clinical Supervision. This is a project being conducted by Robbin Durham LICSW, Assistant Professor of Social Work at Concord University and Samantha Byrd LGSW, Grant Manager Social Work Department, Concord University. It should take approximately 5-10 minutes to complete.

Your participation in this survey is voluntary. You may refuse to take part and exit the survey at any time without penalty. There is a question about your willingness to provide supervision and if you answer “no”, you do not need to complete any additional information.  Only those indicating they are willing to provide supervision and who provide contact information will be included on the list.

You will receive no direct benefits from participating in this online survey. However, your responses will help streamline the process for those seeking clinical supervision.


There are no foreseeable risks involved in participating in this survey other than those encountered in day-to-day life. Understand that you will likely receive contact from those seeking clinical supervision.

Your survey answers will be utilized to create a master list of eligible clinical supervisors.  The completed list will be available through the WV Board of Social Work and Social Work Schools in WV (Concord University, WV State University, Marshall University, West Liberty University, West Virginia University and Shepherd University). LICSW candidates will be able to request the final list from the above entities.  In providing contact information, be aware that information will appear on the master list.

If you have questions at any time about the study or the procedures, you may contact Robbin Durham at 304-384-5218 or

If you feel you have not been treated according to the descriptions in this form, or that your rights as a participant in research have not been honored during the course of this project, or you have any questions, concerns, or complaints that you wish to address to someone other than the investigator, you may contact the Concord University Institutional Review Board at PO Box 1000, Athens, WV, 24712 or

ELECTRONIC CONSENT: Please select your choice below. Clicking on the “Agree” button indicates that

  • You have read the above information
  • You voluntarily agree to participate
  • You are 18 years of age or older