UNIVERSITY AT BUFFALO, STATE UNIVERSITY OF NEW YORK
Dissociative Amnesia Study
Informed Consent Document

This research study is intended for adult participants who are 18 years of age and over. If you are not yet 18, please do not participate in this study.

This consent form explains the research study. Please read it carefully.

FOR QUESTIONS ABOUT THIS RESEARCH, CONTACT:
This study is being conducted by Molly Wolf, LMSW (mwolf3@buffalo.edu) under the supervision of Dr. Thomas Nochajski (thn@buffalo.edu). Any questions, concerns or complaints that you may have about this study can be answered by Molly Wolf. Ms.Wolf and Dr. Nochajski can be reached through the Social Work Department at the University at Buffalo, Amherst NY 14260 or by telephone at (716) 829-5859.

If you have any questions about your rights as a participant in a research project, or questions, concerns or complaints about the research and wish to speak with someone who is not a member of the research team, you should contact (anonymously, if you wish) the Social and Behavioral Sciences Institutional Review Board, 515 Capen, University at Buffalo, Buffalo, NY 14260, e-mail SBSIRB@research.buffalo.edu, phone (716) 645-6474.

PURPOSE:
You are invited to participate in a clinical research project that examines your experiences of child sexual abuse and related issues concerning that abuse. The results of this study should help to further our understanding of how memory is formed around abusive experiences. This understanding will help us (and other therapists) to develop more effective intervention programs to assist survivors of child sexual abuse. At least 200 participants will be involved in this study.
PROCEDURES:
If you agree to be a part of this study, you will answer a series of questions online. Filling out the questionnaires should take about 30-40 minutes. Most of the questions will be about your experiences of child sexual abuse, your memory of the events, and related issues. You are free not to answer any questions you do not wish to answer. You may withdraw from the study at any time by hitting the ‘x’ at the top right hand corner of the screen. Withdrawing would have no foreseeable negative effects.

CONFIDENTIALITY:
The information you provide by filling out the survey is completely anonymous and therefore no one will be able to identify your responses. The data from your survey will be retained indefinitely for use in future studies. Your identity will in no way be related to the study.

RISKS:
The known risks associated with this study include the possibility that you might become upset thinking about some of the questions or topics in this study. If this occurs, you should notify the interviewer via e-mail, and you will be provided with an appropriate referral for assistance. Another option always available to you is to stop participating in the study by hitting the X at the top right of your computer screen.

BENEFITS:
There are no anticipated direct benefits to you for participating in this study but the study will assist researchers and clinicians in having a more complete picture of the effects of child sexual abuse on adults who have survived it. This in turn could result in the formation of better prevention and intervention programs.

COSTS and COMPENSATION:
There is no cost to you for participation in this research. There is no compensation provided for participation in this study.

JOINING OF YOUR OWN FREE WILL (VOLUNTEERING FOR THE STUDY):
Your participation is voluntary. Your refusal to participate will involve no penalty. You do not have to answer every question and may refuse to answer any questions that you do not want to answer. You may withdraw from the study at any time by contacting the investigator and all data that can still be identifiably attributed to you will be withdrawn by the investigator.