Question Title

* 1. CONSENT FORM

Invitation to Participate: You are being invited to participate in a research study entitled "Effect of Mental Representations in Attachment Styles & Reflective Functioning in Adults" that is being conducted by Carlton Jama Adams, assistant professor at John Jay College, and Khrys-Ann Josephs, undergraduate student at John Jay College. We would like your permission to fill out a questionnaire that will help us understand how you view your relationship and attachments.

Purpose & Participant Enrollment: If you agree to participate, you will be asked to fill out an on-line questionnaire about how you view different social groups. You will then be asked to answer some questions about yourself. The questionnaire should take around 15 minutes to complete. There will be approximately 150 participants taking part in the study. At any time and for any reason, you can refuse to answer a question or stop filling out the questionnaire by clicking on the “Exit Survey” button.

Risks & Benefits: There are no foreseeable risks to participating in the study. The direct benefits to you are minimal, but we do think the study will make a contribution to social psychology and our understanding of how people perceive one another.

Voluntary Participation: Your participation in this study is completely voluntary. You have a right to refuse to participate without consequences or discontinue your participation at any time without penalty. You may refuse to answer any specific questions or refuse to engage in any task at any time during the study. Withdrawal or refusing to answer specific questions or engage in specific tasks will not result in any consequences to you. In sum, you do not have to be in this study if you do not want to. If you agree to be in the study, but later change your mind, you may stop at any time.

Data: If you agree to participate, an ID code will be assigned to your responses. Your ID code will not be linked to your name and there will be no way link your responses back to you. You will remain completely anonymous, except in the event that you include your name at the end of the questionnaire. Once the data collection is complete, your name will be removed from the file that contains your responses to the questionnaire. We may publish results of the study, but the names of people or any identifying characteristics, will not be used in any of the publications. If you would like a copy of the results of the study, please provide us with your email address and will send you a copy some time in the future.

Questions: If you have any questions about this research, you can contact Dr.Carlton Jama Adams at (212)-237-8761 or cadams@jjay.cuny.edu or Khrys-Ann Josephs at khrys-ann.josephs@jjay.cuny.edu.

The study described above has been explained to me. I understand that future questions I may have about the research will be answered promptly by the investigators listed above. If I have any questions about my rights as a participant, I may contact the John Jay Institutional Review Board Office at (212) 237-8961 or by email: jjirb@jjay.cuny.edu. I understand I may print a copy of this form for my records.

By selecting "yes", the subject certifies that he/she is at least 18 years of age.

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