INFORMED CONSENT FORM
Study Title: Education, work and mental health: impacts on senior volunteerism: in the midwest
Researcher: Jesse O. Bolinger
Email Address and Telephone Number: firstname.lastname@example.org 641-455-2896
Research Supervisor: Dr. Jesse O. Bolinger, CNP, PhD
The study researcher wants to know if you would like to be part of a research study. The researcher is an independent researcher. This form describes the study in order to help you decide if you want to participate. This form will tell you what you will have to do during the study and the risks and benefits of the study.
If you have any questions about or do not understand something in this form, you should ask the researcher. You should discuss your participation with anyone you choose in order to better understand this study and your options. Do not sign this form unless the researcher has answered your questions and you decide that you want to be part of this study.
WHAT IS THIS STUDY ABOUT?
The researcher wants to find out what people think about volunteerism in the midwestern United States communities. The researcher is interested in learning how past work experience, educational background and mental health impact an individuals selection of volunteer positions.
The researcher will ask participants questions about the participants work and education background as well as personal beliefs and how the individual maintains a positive level of mental health.
It is planned that about 12-20 participants will be in this study. All participants will be 65 years of age and older.
Why am i being asked to be in the study?
You are invited to be in the study because you are:
65 years of age or older
A resident a state in the midwestern United States
Currently, or have been a volunteer, in the past 6 months
If you do not meet the description above, you are not able to be in the study.
Who is paying for this study?
The researcher is not receiving funds to conduct this study.
WILL IT COST ANYTHING TO BE IN THIS STUDY?
You do not have to pay to be in the study.
How long will I be in the study?
If you decide to participate in this study, your participation will last for the duration of this written survey.
WHAT WILL HAPPEN DURING THIS STUDY?
Before you can start the study, the researcher will talk to you about the study. Then you must sign this form before you begin the study.
After you sign this form, the researcher will do the things listed below:
Demographic Questions: Ask you to give personal information about yourself, such as your age, gender, occupation, education level, etc.
Questions: Ask you to answer questions about past work and education experience, mental health and your personal background.
WILL BEING IN THIS STUDY HELP ME?
Being in this study will not help you. Information from this study might help researchers help others in the future.
ARE THERE RISKS TO ME IF I AM IN THIS STUDY?
No study is completely risk-free. However, we don’t anticipate that you will be harmed or distressed during this study. You may stop being in the study at any time if you become uncomfortable.
DO I HAVE TO BE IN THIS STUDY?
Your participation in this study is voluntary. You can decide not to be in the study and you can change your mind about being in the study at any time. There will be no penalty to you. If you want to stop being in the study, please exit the survey.
WHO WILL USE AND SHARE INFORMATION ABOUT MY BEING IN THIS STUDY?
Any information you provide in this study that could identify you such as your name, age, or other personal information will be kept confidential. Your personal information will be kept separate from your answers. Additionally, your answers will be coded with an identification code. These codes will be stored separate from other data.. In any written reports or publications, no one will be able to identify you.
The researcher will keep the information you provide in a password protected computer and a locked storage area. in the researchers home and only the researcher and research supervisor will be able to review this information.
Even if you leave the study early, the researcher may still be able to use your data. Data may still be utilized if you provided information that would be helpful in answering the research questions and if there are not enough participants remaining in the study after you leave the study.
Limits of Privacy (Confidentiality)
Generally speaking, the researcher can assure you that she/he will keep everything you tell him/her or do for the study private. Yet there are times where the researcher cannot keep things private (confidential). The researcher cannot keep things private (confidential) when:
The researcher finds out that a child or vulnerable adult has been abused
The researcher finds out that that a person plans to hurt him or herself, such as commit suicide,
The researcher finds out that a person plans to hurt someone else,
There are laws that require many professionals to take action if they think a person might harm themselves or another, or if a child or adult is being abused. In addition, there are guidelines that researchers must follow to make sure all people are treated with respect and kept safe. In most states, there is a government agency that must be told if someone is being abused or plans to hurt themselves or another person. Please ask any questions you may have about this issue before agreeing to be in the study. It is important that you do not feel betrayed if it turns out that the researcher cannot keep some things private.
WHO CAN I TALK TO ABOUT THIS STUDY?
You can ask questions about the study at any time. You can call the researcher at any time if you have any concerns or complaints. You should call the researcher at the phone number listed at the top of this page if you have questions about the study procedures, study costs (if any), study payment (if any), or if you get hurt or sick during the study.
DO YOU WANT TO BE IN THIS STUDY?
By being in the study, I agree to the following statement:
I have read this form, and I know how to contact the researcher in order to ask questions prior to completing this survey.
I have not given up any of my legal rights as a research participant. I understand that I can save, print or copy this form for my records if I choose to do so.
I attest that the participant had enough time to consider this information, had an opportunity to ask questions, and voluntarily agreed to be in this study.
By completing the survey, I consent to my participation in the study.