Consent and Demographic Information

Dear Foundation Member,

You are invited to join a research study looking at coping style as a mediator for depression, anxiety, and quality of life during active and inactive phases of autoimmune disease. Please take whatever time you need to discuss the study with your family and friends, or anyone else you wish to. The decision to join, or not to join, is up to you. If you decide to participate, you will be asked to complete a set of brief surveys which will take approximately 15 minutes to complete. Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study at any time, there will be no penalty. If at any time you discontinue the survey, your results will be discarded. This questionnaire is confidential. Identifying information will not be collected, as it is anonymous. To further preserve your confidentiality, geolocation will be disabled by hiding the IP address on the survey website, and the information will be kept on a password protected computer. The risks of the study are potential for bringing to light some of the unwanted symptoms you may be currently experiencing. The potential benefits of the study include increased awareness and use of behavioral techniques to cope with disease flare-ups. However, we can’t guarantee that you will personally experience benefits from participating in this study. Others may benefit in the future from the information we find in this study.  If you have any questions concerning the research study, please call my faculty advisor Dr. Lorna London at 630-515-7498 or e-mail me at halex84@midwestern.edu. This research has been approved the University of Midwestern’s Institutional Review Board. If you have any questions about your rights as a subject/participant in this research, or if you feel you have been placed at risk, you can contact Dr. Sean Lynch, the Chair of the Human Subjects Committee, Institutional Review Board at 630-515-6156. Additional contact information is available at www.midwestern.edu/orsp _-_home_/student_research.html. You must be 18 or older to participate and have been diagnosed with one if the following autoimmune diseases: alopecia areata, rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, inflammatory bowel disease, or type 1 diabetes. By checking the box below, you are providing your consent to participate. Please do not skip any answers. If a question does not apply to you, please pick the best choice. Thank you.

Sincerely,

Helen Alex, M.A.

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* 1. Dear Foundation Member,

You are invited to join a research study looking at coping style as a mediator for depression, anxiety, and quality of life during active and inactive phases of autoimmune disease. Please take whatever time you need to discuss the study with your family and friends, or anyone else you wish to. The decision to join, or not to join, is up to you. If you decide to participate, you will be asked to complete a set of brief surveys which will take approximately 15 minutes to complete. Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study at any time, there will be no penalty. If at any time you discontinue the survey, your results will be discarded. This questionnaire is confidential. Identifying information will not be collected, as it is anonymous. To further preserve your confidentiality, geolocation will be disabled by hiding the IP address on the survey website, and the information will be kept on a password protected computer. The risks of the study are potential for bringing to light some of the unwanted symptoms you may be currently experiencing. The potential benefits of the study include increased awareness and use of behavioral techniques to cope with disease flare-ups. However, we can’t guarantee that you will personally experience benefits from participating in this study. Others may benefit in the future from the information we find in this study.  If you have any questions concerning the research study, please call my faculty advisor Dr. Lorna London at 630-515-7498 or e-mail me at halex84@midwestern.edu. This research has been approved the University of Midwestern’s Institutional Review Board. If you have any questions about your rights as a subject/participant in this research, or if you feel you have been placed at risk, you can contact Dr. Sean Lynch, the Chair of the Human Subjects Committee, Institutional Review Board at 630-515-6156. Additional contact information is available at www.midwestern.edu/orsp _-_home_/student_research.html. You must be 18 or older to participate and have been diagnosed with one if the following autoimmune diseases: alopecia areata, rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, inflammatory bowel disease, or type 1 diabetes. By checking the box below, you are providing your consent to participate. Please do not skip any answers. If a question does not apply to you, please pick the best choice. Thank you.

Sincerely,

Helen Alex, M.A.

What is your age?

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* 2. What is your age?

Please mark the box that indicates your race or ethnicity

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* 3. Please mark the box that indicates your race or ethnicity

Please mark the box that indicates the autoimmune disease you have been diagnosed with.

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* 4. Please mark the box that indicates the autoimmune disease you have been diagnosed with.

Please mark the box that best describes the phase of disease you are in

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* 5. Please mark the box that best describes the phase of disease you are in

Please indicate any comorbid medical conditions you are currently experiencing.

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* 6. Please indicate any comorbid medical conditions you are currently experiencing.

Please indicate if you are currently using outpatient mental health services and if you have been diagnosed with a psychiatric disorder.

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* 7. Please indicate if you are currently using outpatient mental health services and if you have been diagnosed with a psychiatric disorder.

Please indicate below any psychiatric medications you are currently taking.

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* 8. Please indicate below any psychiatric medications you are currently taking.

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