Participant form

DATA PRIVACY: The data that you enter on this form will be stored in a Google Document and subject to Google's privacy policies, which are described here: http://www.google.com/policies/privacy/. This is the same privacy policy that applies to emails sent via Gmail. So, from a data privacy perspective, entering data using this form is equivalent to sending an email with this data to a Gmail email account. The data you enter on this form is the ONLY data from this study stored on Google servers. ALL other data related to our research is be stored on secure servers maintained by our research laboratory. If you are uncomfortable entering your information using this form, please read the study information below, and if you are still eligible please contact the research coordinator at megan.powell@colorado.edu.
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Consent

Screening Protocol for Clinical Experience and Pain Study Principal Investigator Tor Wager PARTICIPANT INFORMED CONSENT FORM Part A: Online Screening V3.0. 3/19/2013 Please read the following material that explains this research study. Signing this form will indicate that you have been informed about the study and that you want to participate. We want you to understand what you are being asked to do and what risks and benefits—if any— are associated with the study. This should help you decide whether or not you want to participate in the study. CONTACT INFORMATION You are being asked to take part in a research project conducted by Tor Wager, Ph.D. a faculty/staff member in the University of Colorado at Boulder’s Department of Psychology, 345 UCB, Boulder, CO 80309­0345. Tor Wager can be reached at 303­-492-­7487. PROJECT DESCRIPTION The goal of the Principal Investigator’s research is to gain a better understanding of the psychological and physiological processes underlying the clinical experience and pain. Because this study has several important requirements, we use a screening process to make sure that we only recruit people who are eligible to participate. The surveys and questionnaires that you complete in this screening will help us determine whether you are eligible to participate. PROCEDURES Taking part in this study is completely voluntary. You do not have to participate if you don't want to. You may also leave the study at any time. If you leave the study before it is finished, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. However, you will not be able to participate in any pain studies in our lab. Description of Procedures If you agree to take part in this study, you will answer a short questionnaire online. This will take about 5 to 10 minutes. After you complete the questionnaire, a member of our lab will review your responses. If you are eligible to, someone from our lab will send you an email with a link to the first part of the research study, another online questionnaire. In this questionnaire we will we will collect some additional information about you and your availability to come in for your 2-hour visit to the lab. When you come into the lab, you will fill out some more questionnaires and participate in some simulated clinical interactions involving a basic pain test. You will receive more information about that part of the study if you are invited to come in to the lab. Note that agreeing to participate in this online screening does NOT commit you to participating in any other aspects of the study; you are always free to refuse further participation at any time. Description of What the Online Screening Measure will Ask About The survey measures you will fill out as part of this online screening may ask you about any or all of the following: • Your contact information • Your demographic background • Your medical history, including questions about any history of pain disorders, psychiatric diagnoses, and substance abuse • Your personality You are welcome to skip any question you prefer not to answer; however, please note that some questions require a response in order for us to determine whether you are eligible to participate in pain studies. These questions will be marked with an asterisk. Time Commitment to Complete Research Procedures Completing the survey measures will take about 5 to 10 minutes. Research Location The first part of this screening will take place on the web. If you are invited to participate in lab studies, they will take place at the University of Colorado Boulder Center for Innovation and Creativity located off campus at 1777 Exposition Dr, Boulder, CO 80301. RISKS AND DISCOMFORTS The primary risk of participating in this online screening is a potential loss of confidentiality and/or privacy. As part of the screening, you will be asked sensitive questions about your medical history and any history of illegal substance abuse. Although it’s extremely unlikely, please be aware that your answers could potentially be requested by the police or the courts and used against you. We will take thorough precautions to ensure that your data is kept secure, and we will never voluntarily share your responses to sensitive questions with anyone outside of the research team unless legally obligated to do so. However, we cannot guarantee with 100% certainty that your data will remain secure. BENEFITS There is no direct benefit to you for taking part in this study. However, your participation in this study, and potentially others, will help us develop a better understanding of the psychological and physiological mechanisms underlying the clinical experience and the experience of pain. SOURCE OF FUNDING Funding for this study is being provided by the National Institutes of Health (NIH). The NIH is a federal agency that requires that data be collected in a form that permits for differences between men and women and races or ethnic groups to be analyzed. SUBJECT PAYMENT You will not be paid for the basic online screening, which will take approximately 5 – 10 minutes. Once you complete the basic screening, you may be offered the chance to participate in additional pain studies in our lab. You will be paid separately in cash for each study you participate in (generally between $12 and $25 per hour). ENDING YOUR PARTICIPATION You have the right to withdraw your consent or stop participating at any time. You have the right to refuse to answer any question(s) or refuse to participate in any procedure for any reason. Refusing to participate in this study will not result in any penalty or loss of benefits to which you are otherwise entitled, though as noted, we may not be able to determine your eligibility to participate in additional studies. The investigators reserve the right to withdraw you from the study for reasons that they deem necessary for your safety, or if you fail to comply with study procedures. In addition to the research to which you are consenting under this study, we are requesting your permission to save your responses to the online screening questions, including your contact information, so that we may contact you about other potential study opportunities. In the unlikely event of a security breach, your responses could be linked back to you. However, we will take thorough precautions to ensure that your data is protected, and will never share your data will anyone outside the research team unless legally obligated to do so. Please note that we will remove your data from our database at any time upon request. Your information will be kept in our database indefinitely. Any future use of this information that is not already approved under this document would have to be approved by an ethics committee, also known as an Institutional Review Board (IRB). The IRB may ask us to talk to you again before doing the research, or it may let us do the research without talking to you again if we keep your information private.

CONFIDENTIALITY We will make every effort to maintain the privacy of your data. Your information will be kept in a secure, password­protected database, and we will not maintain paper records of your participation other than any consent forms you sign (if you visit our lab). Other than the researchers, only regulatory agencies such as the Office of Human Research Protections and the University of Colorado at Boulder Institutional Review Board may see your individual data as part of routine audits. QUESITONS? If you have any questions regarding your participation in this research, you should ask the investigator before signing this form. If you should have questions or concerns during or after your participation, please contact the research coordinator, Dr. Tal Yarkoni, at 303-­492-4299. If you have questions regarding your rights as a participant, any concerns regarding this project or any dissatisfaction with any aspect of this study, you may report them ­­ confidentially, if you wish ­­ to the Institutional Review Board, 3100 Marine Street, Rm A15, 563 UCB, 303-735-­3702.