1. Minority Women Survey

Dear Participant:


My name is Thomas D. Avery.  I am a doctoral student at Northcentral University. I am

doing a research study on the underrepresentation of minority women engineers as part of my




You will be asked to complete an online survey. Your participation will require less

than 6 minutes of your time.

Eligibility: You are eligible to participate in this research if you 18 years or older.

Also, you must have visited your local hospital or a clinic in the last 12 months. You

are not eligible to participate in this study if you are a minor.

Risks: There is a minimal risk in this study.

Benefits: There are no direct benefits to you, if you decide to participate.

Confidentiality: The information you provide will be kept confidential. I will take

steps to keep your identity confidential and I will not ask for your name. The people

who will have access to your information are myself, my chair, and my dissertation.

committee I will secure the answers on a flash drive that will be kept locked in a

filing cabinet.  The survey answers will not be printed off.  I will keep your data for 7

years.  Then, I will delete electronic data by destroying the flash drive.

Contact Information: If you have questions, you can contact me at:

Thomas D. Avery

Doctoral Candidate and Principal Investigator – Northcentral University

E-mail: T.Avery0247@o365.ncu.edu

Telephone: 601-896-2338

My dissertation chair’s name is Dr. Gary White, PhD. He works at Northcentral

University and is supervising me on the research.  You can contact him at:

garywhite@ncu.edu or 215-757-6759.

If you have questions about your rights in the research, or if a problem happens, or if

you are injured during your participation, please contact the Institutional Review

Board at: irb@ncu.edu or 1-888-327-2877 ext. 8014.


Voluntary Participation: Your participation is voluntary.  There will be no penalty to

you if you decide not to participate, or if you stop participation after you start.  If you

begin filling out the survey and decide to withdraw, your answers will not be saved.  Just click the Exit Link located in the upper-right corner of every page.  This will allow you to leave the survey and your responses will not be stored.

Collected data will be saved once the survey is complete and your responses will not

be able to be removed after that time.  If you understand and agree with the informed consent provided, please click Next to proceed and complete the survey.

Thank you for your time and participation in this survey.