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The Role of Education, Socioeconomic Status, and Substance Abuse in Predicting Intimate Partner Violence Revictimization
Undergraduate Students at California State University, Chico
CONSENT TO PARTICIPATE IN A RESEARCH PROJECT
You are invited to participate in a research project conducted by Angela Buckner, Aurelio Guzman, Allysa LePage, and Bertha Ramos, candidates from California State University, Chico (CSU, Chico) Master of Social Work program. The research project hopes to gain insights into predictors of intimate partner violence (IPV) revictimization. This research project is being conducted in partial fulfillment of the requirements for a master’s degree, under the supervision of Dr. Judy Vang at CSU, Chico. The project is including at least 60 adults, ages 18 and older, who identify as being an undergraduate student at CSU, Chico.
If you decide to participate, you will be asked to respond to a survey questionnaire. The survey will include questions about your age, gender, ethnicity, income, educational attainment, use of drugs and alcohol, and experience with IPV. The survey should take approximately 15 minutes to complete. While participating in this project, it is possible that you may feel some discomfort in answering some of the questions. Should the questions trigger some discomfort, please notify the administrator(s). You always have the options to skip the question(s) or withdraw from the project. Please be mindful that there is no penalty should you skip particular interview questions or withdraw from the project.
Your name or any other identifying information will not be written on your survey and your signed consent form will be stored in a secure file separately from your survey. Any information that you share with the researchers will be kept confidential. However, as graduate social work students, the researchers are mandated reporters. Thus, should you disclose current thoughts of harming yourself or others, the student researchers will have an ethical responsibility to contact the appropriate authorities in order to protect your health and the community. Everyone in the project will be given a list of community resources, and the survey administrators are available to help you connect to community resources, if you desire. You may not receive any direct benefit from taking part in this project; however the project may serve to increase knowledge in this area, which may help others in the future.
Your participation is voluntary. You do not have to take part in this project, and whether or not you take part in this project will not affect your course grades or other treatment by your academic institution. If you have questions about the project itself, please contact: Angela Buckner at [email protected], or Aurelio Guzman at [email protected], or Allysa LePage at [email protected], or Bertha Ramos at [email protected], or their faculty adviser, Dr. Judy Vang at 530-700-0000 or [email protected].
Your signature indicates that you have read and understood the information above, and agree to take part in this project. Please understand that you may withdraw your consent at any time without penalty, and that by agreeing, you are not waiving any legal claims, rights or remedies. The student researcher(s) will provide you with a copy of this form for your own records. |
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| What is your ethnicity? (Please select all that apply.) |
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| What is your gender identity? |
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| What is your annual household income? |
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| What is the highest level of education that you have completed? |
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| Do you drink alcohol? If yes, how much alcohol do you consume per week? |
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| Do you ever use recreational drugs (i.e., marijuana, methamphetamine, cocaine, LSD, ecstasy, prescription narcotics, etc.)? If yes, how often? |
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| Have you, or someone that you know, been a victim of IPV more than once (either with the same partner or a different one)? (Please select all that apply.) |
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| Are you familiar with or do you know someone who has used local domestic violence services (Catalyst, etc.)? |
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