HCAP 4900 - Informed Consent & Survey Instrument Examples.docx

HCAP 4900 - Informed Consent & Survey Instrument Examples.docx

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1 Informed Consent: Participants 18 Years of Age and Older Dear Student, My name is Jane Doe, and I am a student at Tennessee State University working on a B.S. degree in Health Administration. I am conducting a research study entitled A Correlational Analysis of Self-Esteem Levels and Knowledge of Risky Behaviors among Female Freshman College Students. The purpose of this quantitative correlational research study is to determine through statistical comparisons any significant differences between knowledge of risky behaviors and self-esteem levels of first-time female college students at an institution of higher learning in middle Tennessee. Your participation will involve you completing an on-site paper and pencil survey, which will take approximately 15 minutes. You will be asked to answer questions pertaining to self-esteem and knowledge of risk-taking behaviors. You will also be asked your age, gender, race, sexual orientation, socio-economic status, and educational background. Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study at any time, you can do so without penalty or loss of benefit to yourself. The results of the research study may be published but your identity will remain confidential and your name will not be disclosed to any outside party. In this research, there are no foreseeable risks, but you may experience uncomfortable feelings due to the personal nature of some questions. Although there may be no direct benefit to you, a possible benefit of your participation is understanding the relationship between self-esteem levels and knowledge of risky behaviors, which may improve the physical and mental health conditions of young women. If you have any questions concerning the research study, please call me at 615 ____________ or by e- mail__________. As a participant in this study, you should understand the following: 1. You may decline to participate or withdraw from participation at any time without consequences. 2. Your identity will be kept confidential. 3. Jane Doe, the researcher, has thoroughly explained the parameters of the research study and all of your questions and concerns have been addressed. 4. Data will be stored in a secure and locked area. The data will be held for a period of three years, and then destroyed. 5. The research results will be used for publication. “By signing this form you acknowledge that you understand the nature of the study, the potential risks to you as a participant, and the means by which your identity will be kept confidential. Your signature on this form also indicates that you are 18 years old or older and that you give your permission to voluntarily serve s a participant in the study described.” Signature of research participant___________________________ Date _____________ Signature of researcher ___________________________________Date ______________ 1
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