Informed Consent Form: Chronic Pain Questionnaire

You are invited to participate in a research study conducted by a team of researchers at Westminster College under the guidance of Dr. Lesa Ellis in the Neuroscience Department and Dr. Jennifer Simonds in the Psychology Department. Thank you for considering participation in our project.

The following describes the purpose, procedures, benefits, risks, discomforts, and precautions of this portion of the study. It also describes the right to withdraw from the study at any time. It is important to note that refusal to participate will not affect any Westminster student’s class standing or academics in any way.

You will be asked to spend approximately 20 minutes completing questionnaires about different aspects of your personality, temperament, and chronic pain experience. We think that the longest questionnaire takes approximately 10 minutes and the shortest takes approximately 5 minutes.

There are no foreseeable risks associated with participation of this study. All participants will have the opportunity to enter into a drawing of prizes donated by local Salt Lake City businesses by providing an email address. If you are selected for one of these prizes, you will be contacted via email for mailing information. You do not need to provide your name in order to receive a prize. You may have already benefited from participating in this study by receiving extra credit in a May Term or Spring semester course last year. However, not all teachers distributed extra credit for your participation at that time. However, at minimum, you will derive an educational benefit from experiencing a research study from the perspective of a participant.

Some participants may find the questionnaires boring or may find some questions difficult to answer. You may discontinue your participation at any time simply by closing your browser window. You do not have to answer any questions that make you feel uncomfortable. However, we understand that participation in this study may also involve risks that are currently unforeseeable.

All information collected in this study will be completely confidential. You will be assigned a number and all the data collected will be identified by that number and stored in a computer in a locked office at Westminster College. This form will be stored separately in a binder kept in the locked office of Dr. Lesa Ellis or the locked office of Dr. Jennifer Simonds.

Any questions that you may have concerning any aspect of this investigation will be answered by Dr. Lesa Ellis at 801-832-2425 ( or Dr. Jennifer Simonds at 801-832-2414 ( In addition, if you have any questions regarding your rights as a research participant, you may contact Dr. Robert Shaw, chair of the Institutional Review Board at Westminster College, at 801-832-2474 (

“I understand that I will not receive any payment for participation in this study other that the possible random selection of my email address for prizes donated by Salt Lake City vendors. However, tests, procedures, or other costs incurred solely for purposes of research will not be my financial responsibility."

"I understand that I am free to withdraw from this investigation at any time."

By entering your initials below, you are agreeing that you have read and understood the above form.

* 1. PARTICIPANT’S INITIALS (electronic signature):