National Brain Injury (BI) Study of Disability Disclosure in the Workplace

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Consent Form

Project Title: National Brain Injury (BI) Study of Disability Disclosure in the Workplace

1. Why is this research being done?
This is a research project being conducted by Dr. Ellen Fabian and David Burnhill at the University of Maryland, College Park. We are inviting you to participate in this research project because you have had a BI. The research project is designed to explore the elements involved in disclosing a disability to an employer for persons with BI.

2. What will I be asked to do?
You will be asked to complete a survey which consists of 54 items. The survey will take approximately 20-30 minutes to complete. After completing the survey, you may choose to participate in a raffle for a chance to win one of five $25 VISA gift certificates by providing your contact information in the last section of the survey.

3. What about confidentiality?
We will do our best to keep your personal information confidential; however, please note that potential threats to securing confidentiality are possible on all web-based servers. Given this information, please understand that your name, contact information, e-mail address, and your survey responses will not be linked together; therefore, your responses will be anonymous. You will only be providing your name and contact information after completing the survey if you choose to participate in the raffle. Once the raffle results are complete, your name and contact information will be destroyed. All collected data with identifiable information will be kept in password protected computer files, locked file cabinets, and storage areas. Once the data is analyzed and the research results are documented, the data will be deleted from the computers and all paper materials will be shredded. If we write a report or article about this research project, your identity will be protected to the maximum extent possible.

4. What are the risks of this research?
There are no known risks associated with participating in this research project.

5. What are the benefits of this research?
This research is not designed to help you personally, but the results may help the researchers learn more about the elements involved in disclosing a disability in the workplace for individuals who have had a BI.

6. Do I have to be in this research? Can I stop participating at any time?
Your participation in this research is completely voluntary. You may choose not to take part at all. If you decide to participate in this research, you may stop participating at any time. If you decide not to participate in this study or you stop participating at any time, you will not be penalize or lose any benefits to which you otherwise qualify.

7. What if I have questions?
If you have any questions about the research study itself or need alternative formats of the survey, you can contact us by e-mail at efabian@umd.edu, dburnhil@umd.edu or phone at 301-405-2872 or 301-675-3713. If you have any questions about your rights as a research subject or wish to report a research-related injury, please contact the Institutional Review Board by e-mail at irb@deans.umd.edu, by phone at 301-405-0678, or by mail at the Institutional Review Board Office, University of Maryland, College Park 20742.

8. Statement of Age of Subject and Consent
By agreeing to participate in the research project, you are indicating that (a) you are at least 18 years of age; (b) the research has been explained to you; (c) your questions have been fully answered; and (d) you freely and voluntarily choose to participant in this research project.

By going to the next page, you are agreeing that you have read the information above and agreed to participate in the study! Thank you in advance for taking the time to fill out this survey!