RESEARCH PARTICIPANT CONSENT FORM
VISUAL IMPAIRMENT AND COMMITTED RELATIONSHIPS
Dr. Rose E. Ray, Principal Investigator
Behavioral Sciences
Purdue University Calumet
����������� Hello, my name is Jeannine Hays and I am a graduate student in the department of Marriage and Family Therapy at Purdue University Calumet. Currently, I am conducting research on various aspects of committed relationships. The purpose of this research is to study factors associated with individuals who are visually impaired and the committed relationships that they engage in. The only requirement for this research is that you are currently in a committed relationship (marriage or otherwise) that has had a duration of six months or longer.
If you agree to participate in this research I ask that you and your partner each fill out the questionnaire linked to this page as completely and honestly as possible. After you and your partner complete the questionnaires please hit the "submit" button at the end of the form and both sets of responses will be annonymously emaled to me. Please save this introductory letter for your personal reference. Participation in this study is completely voluntary. If you are not interested in filling out the questionnaire please disregard these materials.
There are several potential benefits of this study. The results of this study will add to the very limited amount of empirical information on the relationships of individuals who are visually impaired. In addition, participation in this research has the potential to provide information that could benefit all of us who are visually impaired.
Because this questionnaire asks personal questions about your relationships and how you handle certain situations it may bring up uncomfortable thoughts or feelings. If you experience any discomfort after completing the questionnaire, please contact me and I will provide you with information about resources in your area.�
Confidentiality Statement ? The researcher agrees to maintain strict confidentiality with regard to characteristics, questionnaire scores, ratings, incidental comments and other information on any person or subject whose data that is reported. The researcher understands that strict confidentiality means that she may not discuss nor divulge, in any manner, a participant?s identifying information in a place where such a discussion may be overheard, nor will she discuss confidential information in a way that would allow an unauthorized person to associate either correctly or incorrectly an identity with such information.� In order to further protect the identity of participants this study is completely anonymous. Therefore, there is no need to include your name anywhere on the research materials.
Consent - By completing the following questionnaire, I understand that my participation in this research is purely voluntary, and that any information that I provide will be kept confidential. I also understand that if I experience any ill effects from completing this questionnaire I can contact the researcher and will be provided with information about therapists and/or resources in my area to help alleviate the discomfort.
Human Subject Statement . If there are concerns about the treatment of research participants, contact the Committee on the Use of Human Research Subjects at Purdue University, ENAD 328, West Lafayette, IN, 14604. The phone number for the Committee?s secretary is 765-494-5942. The e-mail address is [email protected].
Thank you for your time and effort.
Sincerely,
Jeannine M. Hays
Purdue University Calumet
219-989-2027