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Exit Survey
 
 
INFORMED CONSENT FORM

I agree to participate in the research project “Veterans and Depression” being conducted by Rob Jackson—a student in Dr. Lisa Paul’s PSYC 413 course at Northern Illinois University (NIU). I understand that the purpose of this study is to learn more about how PTSD relates to alcoholism and depression.

I understand that completion of this study includes completing measures related to PTSD, alcohol use, and depression. I also understand that my participation will take approximately 10-15 minutes.

I understand that my participation is voluntary and that I may stop my participation at any time without experiencing any penalty or negative consequences. If I have any additional questions, I will contact Dr. Lisa Paul (815-753-0778). I understand that data collection is solely for the purpose of a PSYC 413 class project, and thus, is not a formal research project and was not submitted to the Institutional Review Board (IRB) at NIU for approval.

I understand that I may not receive direct benefit from participating in this research. However, my participation in this project is intended to increase knowledge about how to improve the lives of soldiers after returning from a war; thus, I am helping to contribute to the development of knowledge in this area.

I understand that potential risks and discomfort involved in this study may include answering questions about sensitive information. I understand that I may choose to not respond to any questions that I do not wish to answer. Further, should I find myself upset following my participation; I will contact Dr. Paul or another resource, including the Psychology Services Center (815-753-0591) or the Counseling and Student Development Center (815-753-1206). I understand that my study responses are anonymous, and that neither my name nor any identifying information will be included on any study measures. I understand that any presentation of this data will be at the group, and not individual, level.

I understand that my consent to participate in this project does not constitute a waiver of any legal rights or redress I might have as a result of my participation, and I acknowledge that I will receive a copy of this consent form should I request one.

By checking the Acceptance CheckBox, I agree to participate in this study



 
 
 
 
Demographics Questionnaire

What is your gender?
 
Male
 
Female
 
 
 
What is your age?
 
18 to 24
 
25 to 34
 
35 to 44
 
45 to 54
 
55 to 64
 
65 to 74
 
75 or older
 
 
 
What is the highest level of school that you have completed?
 
Some high school, but no diploma
 
High school diploma (or GED)
 
Some college, but no degree
 
2-year college degree
 
4-year college degree
 
Graduate-level degree
 
None of the above
 
 
 
Which of the following categories best describes your employment status?
 
Employed, working 40 or more hours per week
 
Employed, working 1-39 hours per week
 
Not employed, looking for work
 
Not employed, NOT looking for work
 
Retired
 
Disabled, not able to work
 
 
 
Which of the following best describes your current relationship status?
 
Married
 
Widowed
 
Divorced
 
Separated
 
In a domestic partnership or civil union
 
Single, but cohabiting with a significant other
 
Single, never married
 
 
 
What is your ethnicity? (Please select all that apply.)
 
Hispanic or Latino
 
Not Hispanic or Latino
 
Unknown
 
 
 
What is your racial background? (Please select all that apply)
 
White
 
Black or African-American
 
American Indian or Alaskan Native
 
Asian
 
Native Hawaiian or other Pacific Islander
 
From multiple races

 
 
 
What is your approximate average household income?
 
$0-$24,999
 
$25,000-$49,999
 
$50,000-$74,999
 
$75,000-$99,999
 
$100,000-$124,999
 
$125,000-$149,999
 
$150,000-$174,999
 
$175,000-$199,999
 
$200,000 and up
 
 
 
* Do you have combat exposure?
 
Yes
 
No