Consent Form


The following survey will take place online from October, 2011 until November, 2011 and will take approximately 25 to 35 minutes to complete. I will be asked to answer questions about my self-esteem, stress, how I deal with stressful events and to answer questions about my sexual behavior and internet use. There is a risk that by answering these questions I might experience some distressing feelings (for example, shame, embarrassment, sadness) and or thoughts (for example, relive past or current stressful experiences).

If I experience any discomfort due to the nature of the questions in the survey and would like assistance I can refer to the following national hotline numbers which are toll-free and available 24 hours a day 7 days a week 1-800-SUICIDE (784-2433) or 1-800-273-TALK (8255). I can also refer to the following information on available resources for assistance with any questions I might have about sexual/reproductive health:

This research is being conducted in order to obtain more information on how females cope with stress and the effects stress has on their self-esteem, sexual behavior and internet use. Although there are no direct benefits to me, the answers I provide might produce valuable information about the way women deal with stress and how it affects self-esteem, sexual behavior and internet use.

By choosing yes I agree to participate in this study, confirm that I am 18 years of age or older, agree that I understand my participation is completely voluntary, I will not be compensated in any way for my participation and understand I may decline to enter this study or withdraw from it at any time without penalty. No identifying information will be collected and all answers will be kept confidential. For specific information about how this will be done I can visit the page “Are my survey responses anonymous and secure?” at I can also find more general information about security on’s privacy policy page at

The account to which the responses will be saved will remain active five years after the study has ended. This account is password protected and can only be accessed by the main researcher, Anabel Patino and the supervising faculty member Dr. Gregg Gold.

If I have any questions regarding the survey and/or my participation I can contact Anabel Patino at (530) 530-329-4189 or The faculty advisor is also available, Dr. Gregg Gold at (707) 826-3740 or

* 1. Do you give your consent to participate in this research project?