1. Study Consent Form

Emory University School of Medicine
Consent to be a Research Subject

Title: Mood States/Itch Quality of Life Survey

Principal Investigator: Suephy Chen, MD, MS
Other Investigators: Seema Kini, MD, MS

Study No.: IRB00035578
Emory University IRB
Study Approved on 4/23/2010

You are being asked to participate in this study because you experience itching, most days of the week, for six weeks or longer. Pruritus (the medical term for itch) is a sensation that makes a person want to scratch. Itch can be debilitating, frustrating, and affect your day to day activities. While the exact cause of an itch is unknown, it is thought to involve chemicals released in the skin and the processing of nerve signals in the brain. The aim of this study is to gain a better understanding of how mood and personality may affect the severity of chronic itch and quality of life of patients with itch.

This form is designed to tell you everything you need to think about before you decide to consent (agree) to be in the study or not to be in the study. At least a few hundred people are expected to participate in this study. This research study is being conducted by Suephy Chen, M.D., M.S. at the Emory University School of Medicine, Department of Dermatology.

Your participation is completely voluntary and you have the right to refuse to be in this study. If you agree to participate, you will be asked to check a box indicating you have read and understand this consent form. Thereafter, you will be directed to a series of 5 electronic surveys that should take about 15-20 minutes to complete in total. These 6 surveys include:

*Demographic questionnaire
*ItchyQol: asks detailed questions relating to your itch
*Beck Depression Inventory: asks questions about your mood
*NEO-Five Factor Inventory: asks you questions relating to your personality
*State Trait Anxiety Inventory: asks you questions about anxiety
*Katz Activities of Daily Living Survey: asks questions about day to day functioning

If you decide to participate in this study, your participation will end once you have completed these surveys.