Thank you for your interest in participating in the following study. Sarah Shadi, B.S., is currently a doctoral student in Clinical Psychology at the Alliant International University, San Francisco, California. This project is approved by the Alliant International University Institutional Review Board. Quyen Tiet, PhD, is the faculty supervisor of Sarah Shadi at Alliant International University, and will supervise the following research.

Title of Study: Feelings of social isolation in a brain injury population.

Purpose of the Study: The purpose of this research project is to create a measure of feelings of social isolation, that is specifically for people who have suffered from a brain injury. In order to qualify for participation in this study you must: Be fluent in English, lived with a brain injury for two years or more, and are between the ages of 18-75.

Measures and Procedures: You will be asked to complete a series of questionnaires surrounding personality style, feelings of social isolation, and feelings of depression. Following the questionnaire, you will be asked to complete a demographic form that asks questions intended to give the researcher more information about the population of people who completed the survey. The questionnaire and demographic form are available in electronic form only.

Duration/Time: Answering these questions will take approximately 30 minutes to 1 hour.

Voluntary Participation: Participation in this research study is completely voluntary. If at any time you wish to discontinue participation, you may simply exit out of the browser. If you wish to learn more about the outcomes of the study you can email the author at SocialIsolationAlliant@gmail.com.

Confidentiality: Raw data will be kept and stored in a password protected Excel file, kept on a password protected external hard drive for five years. This password protected hard drive will be stored in a locked drawer at the principal investigator’s house. The two passwords and the key for the locked drawer, will be given to the co-author of this study. The co-author will also be given the location of the external hard drive in the event that the principal investigator is unable to destroy the data after five years. Once data has been collected and analyzed, it will be deleted from the Qualtrics website by selected “Delete project,” from the drop down menu. Data will be stored on the password protected external hard drive a minimum of five years, compliant with the Systemwide Guidelines for the Protection of Human Participants in Research for Alliant. At the termination of the five year mimimum, the author will permanently delete consent forms from the research folder and then the trash folder on the computer. The author will also de-identify any surveys, original forms, or any other documents that have potential to link the data to a participant. If any participant has emailed the author during the course of the data collection process, the email will be deleted from the inbox, and then from the trash, once an adequate response has been sent.

Foreseeable Risks and Benefits: There is minimal anticipated risk by participating in this study. Participation may invoke feelings of anxiety; however, this potential anxiety should not be greater than what you may feel taking a test at school or going to a doctor’s appointment.

In order to keep anonymity for participants, the researchers will not be able to distinguish between participants in their data. If negative feelings arise from participation, the researchers are unable to reach out to individuals. As a result, the researchers cannot be held responsible for feelings that arise from participation. If you start to feel like taking your life or hurting yourself in anyway during this survey, please call the National Suicide Prevention Hotline at 1-800-273-8255. They are available twenty-four hours a day, seven days a week. The National Suicide Prevention Hotline also provides crisis services based on an individual’s area code.

There are no direct benefits in participating in the following study. The potential overall benefit lays in the potential for future studies in people who are living with a brain injury.

Questions: If you have any questions or concerns regarding the overall research project, please contact the researchers of this study: Sarah Shadi at SocialIsolationAlliant@gmail.com or Quyen Tiet, PhD at qtiet@alliant.edu. If you have any questions regarding participation rights, feel free to contact Alliant International University’s Institutional Review Board at Alliant-irb@alliant.edu or by phone at 858-635-4741. You may print this screen in order to keep a copy of your consent form for your records. Please send an email to SocialIsolationAlliant@gmail.com if you would like more information about the following study. If you start to feel like taking your life or hurting yourself in anyway, please call the National Suicide Prevention Hotline at 1-800-273-8255. They are available twenty-four hours a day, seven days a week.

Approved by Alliant IRB

By clicking yes, you are acknowledging your willingness and intent to participate.