Survey Consent Form

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Survey Consent Form

The Imagery Institute at St. John's University is currently conducting research on parents and the behavior of the self in a mental image. This is a 2-phase study, titled "The Effects of Parental Filters on the Self Image in a Social Anxiety Imagery Task." This online survey (Phase 1) is a preliminary for your potential participation in Phase 2. The purpose of this dual phased study is to examine the effects of thinking about a parent while you picture yourself performing a task in a mental image. These effects will be measured by self-report and psychophysiological recording across the autonomic (for example, heart rate) and central (EEG) nervous systems.

This Phase I online survey is expected to take approximately 30 minutes of your time. If the questions presented cause you any discomfort, you may exit the survey by closing the browser window, and none of your responses will be collected. By completing all the questions presented, you agree that if selected as a candidate, you will consider participating Phase II as well. If the results of your survey suggest that you experience significant levels of social anxiety, we will contact you with referral sources for support.

Only members of the research team will have access to your responses on this survey, which has been designed using Survey Monkey. Survey Monkey is a well-known company that collects data for online survey research, and an encrypted version of this software has been purchased to reduce the risk that responses will be viewed by unauthorized persons. However, a small possibility exists that responses could be viewed by unauthorized third parties, such as computer hackers, since the survey is not being run from a secure http server, such as those used to handle credit card transactions.

After this online survey (Phase I), Phase II will take place onsite at the Imagery Institute located at the Utopia Center, 176-60 Union Turnpike, Suite 325, Flushing, New York, a short walk from the campus grounds. It is expected that full participation will take approximately 1.25 hours on-site. If you are selected to participate in this research, we will contact you. Therefore we request that you provide your email address and/or telephone number at the end of this survey; this is the only identifying information that we will ask you to provide.

If you have questions about this study, please contact Dr. Nancy Bent, Executive Director of the Imagery Institute at St. John’s University at 718.990.8061. If you have any questions or concerns about your rights as a participant in a research study, please contact the St. John’s University Institutional Review Board Chair, Dr. Jay Zimmerman at 718.990.1440.

By completing the statements below, you acknowledge that you understand and agree to the above information. You may then proceed to the next screen for instructions on how to complete the online survey.

We very much appreciate your time and we thank you for your interest!

By signing here, I acknowledge that I have read and understand this consent form, and I agree to the conditions stated above.

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