Consent Form

You are invited to take part in a research study comparing levels of job success and satisfaction between women who experienced intimate partner violence (IPV) and those who have never experienced IPV. The researcher is inviting women over age 18 who have experienced intimate partner violence 5 or more years ago, and women who have never experienced IPV, to be in the study. This form is part of a process called “informed consent” to allow you to understand this study before deciding whether to take part.

This study is being conducted by a researcher named Heather Stark, who is a doctoral student at Walden University. This study is for a dissertation which is part of the work required for completion of that degree.

Background Information:

The purpose of this study is to compare levels of job satisfaction between women who experienced IPV at least five years in the past and women who have never experienced IPV.


If you agree to be in this study, you will be asked to:

•Spend 10 – 20 minutes answering questions about whether you have ever experienced any form of IPV, and questions about your job history, as well as some general questions about your background

•You will not be asked to reveal your name, address or any other specific information that might identify you in the survey. An email address is available for you to contact later if you wish to provide your email address to obtain the results of the study.
Here are some sample questions:

•Have you ever experienced Intimate Partner Violence?

•How much o you agree that you are working in a job that is closely related to your training and education?

•In the past two months, how many times are you more than 30 minutes late to work?

Voluntary Nature of the Study:

This study is voluntary. You are free to accept or turn down the invitation. No one will treat you differently if you decide not to be in the study. If you decide to be in the study now, you can still change your mind later. You may stop at any time.

Risks and Benefits of Being in the Study:

Being in this type of study involves some risk of the minor discomforts that can be encountered in daily life, such stress or reminders of an uncomfortable time or event. Being in this study should not pose risk to your safety or wellbeing.

While the risk of taking this survey is minimal, there is a chance you may be upset or reminded of an upsetting time or event. This survey is designed to minimize the chances of that happening, but If it does happen, you are encouraged to stop the survey and seek assistance from a friend or professional as needed. If you wish to talk about the situation, the Domestic Violence Hotline is free and available round the clock for listening, support, or for referring you to further help. That number is 800-799-SAFE (7233). It is free of charge.

The responses to this survey will help provide information about the long-term effects of IPV on job success and may lead to a wider understanding of how experiencing abuse may affect employment long after the abuse ends. This could lead to further research, greater understanding of the needs for women who have experienced abuse, and discussion of or development of ways to help with job success for survivors of abuse.


Survey participants will not receive any compensation for taking the survey.

Reports coming out of this study will not share the identities of individual participants. Details that might identify participants, such as the location of the study, also will not be shared. No names, addresses or other specific information that could identify participants will be asked. The researcher will not use your personal information for any purpose outside of this research project. Data will be kept secure by being stored on a password protected computer and will be deleted after 5 years.

Contacts and Questions:

If you have questions later, you may contact the researcher If you want to talk privately about your rights as a participant, you can call the Research Participant Advocate at my university at 612-312-1210. Walden University’s approval number for this study is IRB will enter approval number here and it expires on IRB will enter expiration date.

Please print or save this consent form for your records.

Question Title

* 1. Obtaining Your Consent

If you feel you understand the study well enough to make a decision about it, please indicate your consent by clicking the link below and starting the survey.