Eating Habits and Cognitive Style

Consent Form

Brittany Lang
Laura Spiller, PhD, Faculty Advisor
Midwestern State University
Department of Psychology

Human Subjects Review Committee
c/o Office of the Provost
Midwestern State University
3410 Taft Blvd
Wichita Falls, Texas 776308

Title: Eating Habits and Cognitive Styles Survey

Objective & Procedures: The aim of this research is to collect data for a graduate thesis exploring the relation between styles of thinking and concerns about body image and eating. Specifically, questions will ask about eating behaviors, body image, and cognitive styles.

Risks and Benefits: The risk of participating includes discomfort with answering personal questions. For example, a number of questions assess worrisome behaviors (ex. I pinch my stomach to measure fatness) and thoughts (ex. I think checking my body will tell me how I feel).

The potential benefit of the research includes gaining an increased understanding of the precursors to maladaptive eating behavior. Participants may enter their name into a raffle to win a $30 gift card.

Confidentiality: Your responses in this experiment will be anonymous and confidential. No identifying information will be collected as part of this survey. The data will be stored in a secure place, and will be accessible only to researchers directly involved in this study. Results will be reported as aggregate data only.

Voluntary Participation and Right to Discontinue Participation: Your participation in this survey is completely voluntary. If you choose not to participate, your instructor will provide other means of earning research credit. You have the option to discontinue your participation in the study at any time. If you have any questions or experience any adverse effects as a result of participation, you may contact Dr. Spiller or the Midwestern State University Human Subjects Review Committee (see contact information at the top of the page).

Informed Consent: "I have read the description of this study, including the nature and purposes of the study, the procedures to be used, the potential risks and benefits, the confidentiality, as well as the option to discontinue my participation in the study at any time during the session. Each of these items has been described to me fully and I believe I understand what is involved in agreeing to participate. By continuing to the next page of the survey, I indicate that I am at least 18 years old and that I agree to participate in this study."
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