Informed Consent and Debrief assignment PDF

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Summary

this is the consent and debrief form for PSY 452 for experiments being preformed on people that must consent...

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Grand Canyon University College of Doctoral Studies 3300 W. Camelback Road Phoenix, AZ 85017 Phone: 602-639-7804 Email: [email protected]

Instructions: Carefully address the directions in that are specified in purple in each section. This document is very important and it represents you, your chair, and the University; therefore, please pay close attention to detail. Ensure there are no spelling or grammatical errors. The form should be written at an eighth grade reading level in layman’s terms. Evaluate the readability using the calculator below, and provide a screenshot of the readability results as a part of your IRB submission. https://www.webfx.com/tools/read-able/ https://www.online-utility.org/english/readability_test_and_improve.jsp Please delete these instructions before submitting to the IRB for review.

INFORMED CONSENT FORM INTRODUCTION The title of this research study is, Identifying and Diagnosing Dissociative Identity Disorder. I am Ryan Sanne, a doctoral student under the supervision of Dr. Jennifer Brown in the College of Psychology at Grand Canyon University. The purpose of this study is to determine if DID can quickly be identified and diagnosed using the SCID-D interview and fMRI. This study is to help when dealing with court cases involving the defendants claiming DID as a reason for their actions.

RESEARCH KEY INFORMATION This document defines the terms and conditions for consenting to participate in this research study.  How do I know if I can be in this study?  Applicants can be male or female.  Ages 18 and older.  Looking for applicants with acting background but not required.  Looking for applicants that have been diagnosed with DID.  What am I being asked to do? If you agree to be in this study, you will be asked to: take the SCID-D interview which can take 30 minutes to an hour and a half. Next you will have an fMRI completed, which can take 40 to 55 minutes. o What: You will take a questionnaire and undergo a non-invasive fMRI to identify and diagnose DID. o When: These tests will be completed on the same day and assessed as soon as possible. o Where: The tests will be completed at Banner Estrella Medical Center. o How: Trained professionals will administer the SCID-D interview and trained professionals along with Psychology professionals will conduct the fMRI.

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Audiotaping: I would like to use a voice recorder to record your responses. You can still participate if you do not wish to be recorded. Participants will be given numbers as identifiers for all testing and records. Names will be left out for privacy purposes. Videotaping: I would like to use a video camera to record your actions. Because this tape will show who you are, these extra steps will be taken: All tapes will be labeled with participants number not name. They will be locked in a military grade tough box during transportation. You can still participate if you do not wish to be recorded. Participants names will be replaced by numbers when labeling or speaking on video recording.

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Who will have access to my information? Myself, my dissertation chair, other participating researchers, and my dissertation committee.

Participation is voluntary. However, you can leave the study at any time, even if you have not finished, without any penalty or loss of benefits to which you are otherwise entitled. If you decide to stop participation, you may do so by verbally telling the overseeing professional that you no longer wish to participate, at which point proceedings will stop and you will be assisted out of the facility. If so, I will not use the information I gathered from you.

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Any possible risks or discomforts? During this study there are no foreseeable physical risks. There may be the possibility of psychological risks or discomfort during the SCID-D interview, due to the questions. Any direct benefits for me? There are no direct benefits from this testing, unless you are diagnosed with DID and were not originally diagnosed. Any paid compensation for my time? There is currently no paid compensation for your participation in this study. How will my information and/or identity be protected? Participants names will be replaced with corresponding numbers. All information will be saved on a secured computer and locked filing cabinet for 5 years. Only participants will have the ability to link their information to the data collected. Only participants, participating researchers and need-to-know individuals will have access to the collected data.

PRESENTATION OF INFORMATION COLLECTED Data will be grouped together and will be part of a final dissertation. This data will be presented to a committee and only published if instructed that it will be by the committee.

NEW INFORMATION Sometimes during a study we learn new information. This information may come from our research or from other researchers. If new information might relate to your willingness to participate, I will give you that information as soon as possible.

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ADDITIONAL COSTS FOR ILLNESS OR INJURY If you are injured as a result of your participation in this study, treatment will be available to you here: Banner Estrella Medical Center. Additional resources are: continued physical and mental treatment. Costs that arise from injury or emergency treatment must be paid by you.

TERMINATION OF PARTICIPATION I may stop your participation, even if you did not ask me to, if: noticeable mental distress from questionnaire and noticeable physical distress from fMRI. If you decide to stop participation, you may do so by verbally telling one of the participating professionals of the want to stop. If so, I will not use the information I gathered from you.

PRIVACY AND DATA SECURITY   

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Will researchers ever be able to link my data/responses back to me? Unless a new diagnosis of DID is found during the study, there will be no link to the participant and their data. Will my data include information that can identify me (names, addresses, etc.)? No Will researchers assign my data/responses a research ID code to use instead of my name? Yes o If yes, will researchers create a list to link names with their research ID codes? There will be a list created, incase of positive diagnosis found for non-diagnosed participants. o If yes, how will researchers secure the link of names and research ID codes? How long will the link be kept? Who has access? Approximate destroy date? The list will be kept on a secured computer and will only be accessible by the original researcher. The link will be kept for no more than 5 years. July 11th, 2026 is the approximate destruction date. How will my data be protected (electronic and hardcopy)? Where? How long? Who will have access? Approximate destroy or de-identification date? Electronic copies will be kept in a secured computer. Paper copies will be kept in a locked filing cabinet, with both being kept in an identified office at Grand Canyon University. Only participating researchers and need-to-know individuals will have access to data and information. July 11th, 2026 is the approximate destruction date. Where and how will the signed consent forms be secured? Hardcopy consent forms will be locked in the same filing cabinet as all other hardcopy papers collected during the study. Scanned copies will be kept in the same secured laptop.

FUTURE RESEARCH [Please change the language in the sentences below to align with your study] Once identifiers names are removed from these data identifiable private information collected for this study, the de-identified information,could be used for future research studies or distributed to other investigators for future research studies without additional informed consent from you or your legally authorized representative.

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STUDY CONTACTS Any questions you have concerning the research study or your participation in the study, before or after your consent, will be answered by Ryan Sanne at [email protected] or 541-982-9210. If you have questions about your rights as a subject/participant in this research, or if you feel you have been placed at risk, you can contact the Chair of the Human Subjects Institutional Review Board, through the College of Doctoral Studies at [email protected]; (602) 639-7804.

VOLUNTARY CONSENT PARTICIPANT’S RIGHTS  You have been given an opportunity to read and discuss the informed consent and ask questions about this study;  You have been given enough time to consider whether or not you want to participate;  You have read and understand the terms and conditions and agree to take part in this research study;  You understand your participation is voluntary and that you may stop participation at any time without penalty.

Your signature means that you understand your rights listed above and agree to participate in this study ____________________________________________________ Signature of Participant or Legally Authorized Representative

____________________________ Date

INVESTIGATOR’S STATEMENT "I certify that I have explained to the above individual the nature and purpose, the potential benefits and possible risks associated with participation in this research study, have answered any questions that have been raised, and have witnessed the above signature. These elements of Informed Consent conform to the Assurance given by Grand Canyon University to the Office for Human Research Protections to protect the rights of human subjects. I have provided (offered) you a copy of this signed consent document." (Your signature indicates that you have ensured the participant has read, understood, and has had the opportunity to ask questions regarding their participation)

Signature of Investigator______________________________________

Date_____________

DEBRIEFING STATEMENT Thank you for participating in our study. We examined the ability to quickly identify and diagnose DID. You were presented with the SCID-D interview and underwent an fMRI. Our hypothesis was that these two medical tools could quicky identify and diagnose DID. If you would like a copy of the results, send a request to Ryan Sanne at [email protected]. The results should be tabulated in about three weeks. Once again, thank you for your time.

References: GCU IRB_v1.2_012120

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Hall, P., & Steinberg, M. (1994). Systematic assessment of dissociative symptoms and disorders using the SCID-D in a clinical outpatient setting: Three cases. Dissociation, 7(2), 112116. Schlumpf, Y. R., Reinders, A. A., Nijenhuis, E. R., Luechinger, R., van Osch, M. J., & Jäncke, L. (2014). Dissociative part-dependent resting-state activity in dissociative identity disorder: a controlled FMRI perfusion study. PloS one, 9(6), e98795. Yale Medicine. (2021). Functional MRO of the Brain. https://www.yalemedicine.org/conditions/functional-mri-imaging-the-brain

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