UNIVERSITY AT BUFFALO, STATE UNIVERSITY OF NEW YORK
RELATIONSHIPS AND PAST EVENTS
CONSENT FORM

This study has been reviewed and approved by the Social and Behavioral Sciences Institutional Review Board of the University at Buffalo, SUNY. If you have any questions about your rights as a subject in a research project, you should contact (anonymously, if you wish) the Social and Behavioral Sciences Institutional Review Board, Office of the VP-Research, 516 Capen, University at Buffalo, Buffalo, NY, 14260, or by phone 716-645-6474.

FOR QUESTIONS ABOUT THE RESEARCH, CONTACT: Dr. Jaye Derrick, Postdoctoral Associate, 453 Research Institute on Addictions, 1021 Main Street, Buffalo, New York 14203, 716-887-2218, jderrick@ria.buffalo.edu. This consent form explains the research study. Please read it carefully. You may contact me to ask questions about anything you do not understand. If you do not have questions now, you may ask later.

PURPOSE: You are invited to participate in a study on relationships and interpersonal threat.

PROCEDURES: You may be asked to describe a hurtful past event, and you will be asked to complete questionnaires about yourself and your relationship.

TIME COMMITMENT: Your participation in this experiment will take approximately 25 minutes.

RISKS AND BENEFITS: Some participants experience some discomfort in answering some of the questions. There may be no direct benefit to you other than the sense of helping the public at large and contributing to knowledge.

CONFIDENTIALITY: Your data will be collected anonymously. If you wish to participate in the drawing, you may enter your contact information into a form that is completely separate from the current study.

PAYMENT: Participants who complete the experiment will be eligible to participate in a drawing for the chance to win a $25 Amazon.com gift card. You are free to skip any questions that you do not feel comfortable answering. There is no penalty for skipping questions and you will still be eligible for the drawing.

JOINING OF YOUR OWN FREE WILL: Your participation is voluntary. Your refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled. You have the right to refuse to answer particular questions. You have the right to withdraw your data at the end of the session.

If you have any concerns about your interpersonal relationships and wish to seek assistance you may contact Dr. Jaye Derrick, 716-887-2218, jderrick@ria.buffalo.edu, for help locating a counselor or therapist in your area.

PARTICIPANT STATEMENT: I have read this consent form. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate in this study.