Welcome to My Survey

Informed Consent to Participate in Research

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Invitation to Participate:       

Gabriela Pantoja, a graduate student in the Master of Public Health program at California State University, San Marcos is conducting a study on birth outcomes related to maternal depression in pregnant women over the age of 18 and invites you to participate.

Study Purpose: 

The purpose of this study is to collect data from expecting mothers on their emotions, feelings and wellbeing and how these factors may affect birth outcomes of their offspring. During pregnancy there is a range of emotions experienced and prevalence of these emotions may be long term. Therefore, the study aims to observe offspring birth outcomes with emotional wellbeing of the expecting mother. The title of the study is “Emotional Wellbeing During Pregnancy and its Effects on Offspring Birth Outcomes”. You are being asked to participate in the study because you are pregnant and have a likelihood of experiencing emotional changes during your pregnancy.  

Number of Participants:

The number of participants is estimated to be 350.  

Procedures for the Study:
There are two questionnaires as part of the study. The two questionnaires ask questions about demographics followed by questions regarding depression during pregnancy. The follow-up questionnaire will ask questions regarding birth outcomes of newborn including gestational age, birth weight, birth length, and head circumference. The follow-up questionnaire will be sent out the following month to the email address provided by the participant in the initial questionnaire. The follow-up questionnaire will take approximately 15 minutes to complete. 

Risks and Inconveniences: 

The questions may make you feel uncomfortable.
The questionnaire is approximately 15-20 minutes long.


In order to minimize risk such as feeling uncomfortable with the questions being asked or the length of the survey, you can choose to skip any question and at any time discontinue the study and exit from the questionnaire or simply not choose to participate at all. 


The data collected in this study is confidential and any connection between participants and results is not shared in any way. The contact information collected are names, phone numbers, email address, and alternate contact information. A code sheet will be created in order to maintain all  contact information obtained from the participant confidential. The code sheet will include a randomly assigned ID number given to each participant when the survey is submitted in order to link the contact information given from each participant. No names of participants will be used in the research and presentation of the data collected. Once the data has been entered into an electronic database program the original questionnaire will be destroyed and after the data from the follow-up survey is collected and entered all information linking the electronic data to the original questionnaires will be destroyed. The data will be stored for a period of 7 months and then all electronic data will be completed destroyed. The organizations involved in this study include California State University San Marcos. The study requires your permission to collect any data which is not obligatory, and you may choose not to participate in the study before engaging in the study or during. 

Voluntary Participation:   
You are being asked to participate in this study because you are pregnant and may be at risk of or afflicted by maternal depression. However, it is your right whether or not to participate in the study as this study is completely voluntary. The study does not cost you anything and you may discontinue the questionnaire at any moment. 

Benefits of Taking Part in the Study:      
The benefits of enrolling in this study is that data collected can be used for future research that can result in further information on maternal depression and lead to the development of outreach programs and awareness on the effects of depression during pregnancy for young adults as well as all other age groups.

Payment or Incentive:       
Compensation will be given in the form of an opportunity drawing. Participants taking the first survey will be entered for a chance to win a $10 Amazon Gift Card. There will be 7 random winners selected for the first survey and 7 random winners will be selected for the follow-up survey. The gift cards will be emailed to the winners’ email address as a digital gift card. In addition, it is not necessary to answer every question or complete the questionnaire in order to be eligible for the drawing. The winners of the first questionnaire drawing will be randomly selected on March 5th, 2021. The winners of the second questionnaire drawing will be randomly selected on April 7th, 2021. 

Contact Information 
If you have any questions concerning the purpose, procedures, or data collection you are welcomed to contact my advisor Dr.Iyiegbuniwe via email at eiyiegbuniwe@csusm.edu, and or myself, Gabriela Pantoja via email at panto008@cougars.csusm.edu. This study has been approved by the California State University San Marcos Institutional Review Board. Questions about your rights as a research participant should be directed to the Institutional Review Board at irb@csusm.edu or (760) 750-4029. 

Agreement to participate in the study and use my data
I have read this consent form about the study or it was read to me. I understand the possible risks and benefits of this study. I understand and authorize the access, use and disclosure of my information as stated in this form. I know that being in this study is voluntary.  

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* 1. Do you agree to the above terms? By typing your name below, you consent that you are willing to participate in this survey.

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* 2. Do we have permission to contact you for an additional survey?

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* 3. What is your email address?

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* 4. What is the best phone number to reach you at?

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* 5. Alternative Contact's Name:

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* 6. Alternative Contact's Phone Number: