Informed Consent to Participate Online

 

    Alliant International University
California School of Professional Psychology-Sacramento
2030 West El Camino Avenue, Sacramento, CA 95833
(916) 561-3211

 

This consent form is an agreement on your part to participate in research examining perceived ethnic discrimination amongst multiethnic individuals.  The purposes of this project are to:

 

            1) Investigate incidents of perceived ethnic discrimination amongst multiethnic individuals.

           

            2) Provide future researchers with pertinent information regarding perceived         

                 ethnic discrimination in multiethnic individuals.

 

If you agree to participate in the study, you will be asked to complete a modified form of the Perceived Ethnic Discrimination Questionnaire, Community Version (PEDQ-CV), developed by the research team of Elizabeth Brondolo, Ph.D., of St. John’s University in 2005.  You will also be asked to complete a demographic sheet devised by this researcher, James E. Taylor, Clinical Psychology doctoral candidate of Alliant International University (AIU), in Sacramento.  These tasks will take approximately 15 minutes.   

 

By selecting the option of “I agree” found on the button at the end of this form, you are giving this researcher permission to collect psychological data, consisting of ratings of perceived ethnic discrimination, from you as a participant in this research project.  Please be aware that this information will be held confidential to the degree permitted by the technology used.  However, no absolute guarantees can be given for the confidentiality of electronic data.  If you decide to divulge data anonymously, this researcher will be unable to remove anonymous data from the database should you wish to withdraw it.  This researcher will follow American Psychological Association (APA) Ethical Standards, including those for Research with Human Participants when conducting this study.

 

Please be aware that you may participate or withdraw from the study at any time.  You will suffer no penalty of any kind should you choose to withdraw.  Skipping questions is also permissible.  Additionally, you will not receive any direct benefit from participation.

 

Anticipated risks of this study may include triggering emotions that have been associated with perceived ethnic discrimination such as anxiety, anger, or sadness, when reminded of past experiences by PEDQ-CV questions.  If you feel the need to talk with someone regarding thoughts or feelings related to these questions, please let this researcher know and you will be assisted.  If necessary, you will be referred to a therapist.  However, neither this researcher, nor study affiliations will incur the cost of any treatment.

To minimize the level of risk, contact information for the following agencies offering therapy has been provided for online participants:

 

·         American Counseling Association
          (800) 347-6647

 

·         National Resource Center on Homelessness and Mental Illness

          (800) 444-7415

 

·         National Suicide Prevention Lifeline

          (800) 273-TALK (8255)

 

·         S.A.F.E. Alternatives

          (800) DONT CUT (366-8288)

          Spanish-speaking operators available.

 

·         Su Familia (a bilingual service of the Office of Minority Health Resource Center)

          (866) 783-2645

 

If you have any questions or concerns about the conduct of the research, you may reach James E. Taylor at (916) 628-3185.  You may also call the Research Office at the California School of Professional Psychology at (559) 456-2777, extension 2309.

 

Please choose the pull-down button selection of “I agree” if you consent to participate in the study and are at least 18 years of age or “I do not agree” if you do not consent to participate in the study or are under 18 years of age.  “I do not agree” responses will not be allowed to advance to the PEDQ-CV.