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Welcome to My Survey

Informed Consent

Investigator(s): Courtney Renfro
Study Title: The Cultural Implications of Eating Disorders
I am a student at The Chicago School of Professional Psychology. This study is being conducted as a part of my dissertation requirement for The Applied Clinical Psychology program.
I am asking you to participate in a research study about African American women living with eating disorders. You will be asked to participate in a survey. This will take five to ten minutes. This may cause frustration in worry about a lack of confidentiality. Your confidentiality will be protected in this study. Although you may not benefit, it will help to understand more about African American women living with eating disorders.
Please take your time to read the entire document, and feel free to ask any questions before signing this document. 
Purpose: The study aims to find more information on effectively treating African American women living with eating disorders.
 During this study, you will be asked to complete questions related to the treatment needs of African American women with eating disorders. The survey will take 5- 10 minutes to complete.
Risks to Participants:
Confidentiality will be protected, and no identifying information will be used in this study. However, you may feel emotional talking about your patients. I will provide a referral if the survey becomes too overwhelming for you. Here are the referral sources: American Psychological Association and American Counseling Association. The contact information of the American Psychological Association is 1-800-374-2721 and 202-336-5500. The contact information for American Counseling Association is 1-800-347-6647.
Benefits to Participants: You will not benefit from this study. However, we hope the information learned from this study may help society in our understanding of how African American women are living with eating disorders and what are the most effective treatment for this population.
Alternatives to Participation: Participation in this study is voluntary. You may withdraw from study participation at any time without any penalty.
Confidentiality: During this study, information will be collected about you for this research. This includes information on the African American culture, different ways to treat this population, and comparing this culture with the American mainstream culture regarding eating disorders. The online survey administered through Survey Monkey will not collect IP addresses, and no identifying information will be gathered. Research materials will be kept for a minimum of five years after publication per American Psychological Association (APA) guidelines.
It is possible that your data may be used for future research or distributed to another researcher without your consent. However, information that could identify you will be removed.
Your research records may be reviewed by federal agencies whose responsibility is to protect human subjects participating in research, including the Office of Human Research Protections (OHRP) and by representatives from The Chicago School of Professional Psychology Institutional Review Board, a committee that oversees research.

Question Title

* 1. Questions/Concerns: If you have questions about the procedures described in this document, please contact Courtney Renfro at and my dissertation Chair John Shustitzky

Please don’t include any identifying information about yourselves or your clients in the answers you have provided in this survey.


 Clicking below indicates that I have read the description of the study, and I agree to participate in the study.

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