This study is being done by Priya Ratty who is a doctoral student in the Clinical Psychology department at Adler University, Chicago working on a Clinical Research Project. This study is a requirement to fulfill the researcher’s degree and will not be used for decision-making by any organization.
I understand that I have been asked to participate in a research study that will be looking into individuals who have had childhood maltreatment and how they have coped. I understand that to be eligible to participate in this study, I consent that I am between the ages of 18 and 25 years old, am able to communicate in English, I am not currently receiving inpatient or outpatient psychotherapy treatment, I have experienced some form of childhood maltreatment (e.g. physical abuse or emotional abuse or sexual abuse or neglect) in the past and I am not currently facing any ongoing form of maltreatment.
I understand that if I participate, I will be asked to complete an online survey that will take approximately 15 minutes to complete. If I choose, at the completion of the survey I will have the opportunity to engage in a raffle where I can win one of ten Amazon gift certificates with a value of $20. I understand that this survey is anonymous and that no uniquely identifying information is collected; the IP collector on the survey has been disabled. After completing the survey, if I wish to enter the raffle, I will need to provide my e-mail address to the researcher. I understand that the e-mail addresses provided will be kept confidential and not linked to my survey data and only the researcher will have access to the information. I understand that the data for this study will be kept confidential and will be secured by a password-protected computer file, which can only be accessed by the researcher and the researcher’s supervisor. The e-mail address that I provide is not tied to the responses provided.
I understand that this research study has been reviewed and certified by the Institutional Review Board at Adler University, Chicago. I understand that there may be some risk for me of experiencing some discomfort associated with taking part in this study. I understand that this study asks questions about my experience with childhood maltreatment (e.g. physical abuse or emotional abuse or sexual abuse or neglect ) and non-suicidal self-injury (e.g. cutting). I also understand that it is not possible to identify all potential risks in such research, but that all reasonable safeguards will be taken to minimize the potential risks. I understand that the researcher has provided me with a list of resources. These resources are included with this consent form. I understand that I am entitled to the resources and that I should save it or print it out for my records. Upon completion of the survey, I will once again have the opportunity to save the resources if I had not done so in the beginning.
I understand that my participation is completely voluntary and that there is no penalty for refusal to participate. I am free to withdraw my consent, discontinue participation, or retract my contribution at any time. However, once I submit my survey responses, I will not be able to retract them – as the responses are anonymous and cannot be traced back to me. I understand that the data will be kept in a secured file and will be destroyed 3 years after completion of the study.
If at any time I have questions about any procedure in this project, I understand that I may contact the researcher, Priya Ratty, at email@example.com or the researcher’s supervisor, Dr. Leah Horvath, at firstname.lastname@example.org or (312) 662-4358.