Project title: Unusual Experiences Screening Questionnaire
Project #: 2466
Informed Consent Agreement
Please read this consent agreement carefully before you decide to participate in the study.
Purpose of the research study: The purpose of the study is to collect data on and study the frequency and types of different unusual experiences that individuals may experience. Additionally, we hope to identify individuals who have had specific experiences of interest and who would be interested in participating in future research about these experiences.
What you will do in the study: This study will consist of one online questionnaire administered via a secure survey website. The questionnaire will include questions about different experiences you may have had with an optional narrative for each experience. In addition, we will ask you a few questions about yourself and your identity. We will also ask you if you want to participate in future research studies. You can skip any question that makes you uncomfortable or that you do not wish to answer.
Time required: The study will require about 15-30 minutes of your time, depending on how much detail your provide about your experiences.
Risks: There are no anticipated risks in this study.
Benefits: There are no direct benefits to you for participating in this research study. Sharing your experiences with us may generally benefit you by helping you understand these experiences better and helping you understand how they may have affected you. In addition, you may benefit from the opportunity to share personal experiences that one does not often share with others. Data from this study may also benefit future studies aimed toward understanding common themes of some unusual experiences.
Confidentiality: Your responses in the online questionnaire will be handled confidentially, and only by research personnel approved for the study. We will not collect your name. We will specifically ask for your email if you would like to participate in a future research study, and will only use your contact information in case we contact you as a potential participant in future research studies.
Voluntary participation: Your participation in the study is completely voluntary.
Right to withdraw from the study: You have the right to withdraw from the study at any time without penalty.
How to withdraw from the study: If you want to withdraw from the study while you are filling out the online questionnaire, simply close out the browser. There is no penalty for withdrawing. If you would like to withdraw after your online questionnaire has been completed and submitted, please contact Dr. Marieta Pehlivanova whose contact information appears below.
Payment: You will receive no payment for participating in the study.
Using data beyond this study: We will specifically ask for your email if you would like to participate in a future research study.
If you have questions about the study, contact:
Marieta Pehlivanova, Ph.D.
Division of Perceptual Studies
Department of Psychiatry and Neurobehavioral Sciences
University of Virginia Health Systems
P.O. Box 800152
Charlottesville, VA 22908-0152
Telephone: (434) 924-2281
Email: mp8ce@uvahealth.org
To obtain more information about the study, ask questions about the research procedures, express concerns about your participation, or report illness, injury or other problems, please contact:
Tonya R. Moon, Ph.D.
Chair, Institutional Review Board for the Social and Behavioral Sciences
One Morton Dr Suite 500
University of Virginia, P.O. Box 800392
Charlottesville, VA 22908-0392
Telephone: (434) 924-5999
Email: irbsbshelp@virginia.edu
Website: www.virginia.edu/vpr/irb/sbs
Website for Research Participants: http://www.virginia.edu/vpr/participants/
You may print a copy of this form for your records.