Consent Form for Participation in Experimental Research
We are presently conducting an experiment to investigate the reliability and validity of a psychological assessment. Should you agree to participate, you will be asked to complete two questionnaires, one now and the second a week from now. You will be asked to describe psychological symptoms or problems you may be having, as well as aspects of your personality. If there are any questions that are too personal or distressing, you may choose not to answer them. We expect one questionnaire to take about 30 minutes. If you are eligible to receive course credit for research participation in your psychology class (e.g. PSY 1000C), you will receive 2 research credit units (1 unit per half hour).
All of the information you provide to us will be treated with the highest level of confidentiality. Questionnaire results will be scored and coded with a number, and your email address will be discarded once the second questionnaire is completed. Your test results, identified by a numerical ID, will be saved in an encrypted database and statistically analyzed. Your name will not appear anywhere.
By giving your consent to become a participant in this study, you should be aware that you have the right to discontinue your participation at any time and for any reason. If you have any questions pertaining to this study, you may call Adrian Chiu and/or Dr. Jeffery Olsen at the numbers listed below.
Adrian Chiu
Graduate Student
Department of Psychology
St. John's University
(646)217-4697
Dr. Jeffrey Olson
Head of IRB
St. John's University
Jamaica, NY 11439
(718)990-1442I have had the experience of someone pretending to be my friend just to take advantage of me. I often find myself wondering if I can trust friends and/or co-workers. I often choose not to share personal information with others for fear that they will somehow use the information against me at some point. When people do something, I often try to figure out what they really mean. I stay angry at people for a long time if they hurt or insult me. I often feel that others are attacking me somehow indirectly (i.e., in a way that others won't notice). When I am in a relationship I often worry that I am being cheated on. I do have close relationships with friends and/or family members. I almost always choose to do things by myself. I feel that I could happily live my life with no sexual relationships. In general, I really don't take pleasure in most activities in my life. I have close friends other than immediate family members than I can confide in. According to others, I often seem to have no reaction to either criticisms or praise from others. People sometimes say that it's hard to know what I'm thinking or feeling because I don't react with facial expressions or gestures to what they're saying. I sometimes feel like strangers on the street are looking at or talking about me. Sometimes I feel like I can read other people's minds, or predict the future. Sometimes things look or seem different to me, like my eyes are playing tricks on me. People often comment or think that I speak strangely or that I'm hard to follow or understand. People sometimes tell me or feel that I react in a very opposite way than they expected (e.g., laugh instead of cry or laugh out of nowhere). Sometimes I talk to myself. I tend to get nervous around people because I worry about what they might be up to. Sometimes I get very upset because I think someone close to me will leave me. My relationships tend to be stormy, with lots of ups and downs. I often think differently about myself, sometimes to the point of not really knowing who I am. In the past 5 years, how many times have you:
gambled more money than you could afford to lose? bought unnecessary things you could not afford? had one night stands or brief sexual affairs? been intoxicated on alcohol? been stoned or high on other drugs? shoplifted or took something that did not belong to you? been in an auto accident, received a speeding ticket, or been charged with reckless driving? driven while intoxicated or high? gone on eating binges where you at so much food that you had stomach pain or you had to throw up? done anything else impulsive where you could have gotten hurt? There has been at least one time that I've been so upset that I told someone I wanted to hurt or kill myself. There has been at least one time that I have been so upset or tense that I deliberately hurt or injured myself. There have been times when I cut, burned, or bruised myself without having any intention of actually killing myself. I often have days when my mood frequently shifts from feeling fine, to feeling anxious, angry or depressed. I often feel empty inside and in my life. I get angry easily, and stay angry. Sometimes when I'm under stress I feel like things around me or my own body change in size or shape or aren't real. Sometimes when I'm feeling stressed, I get paranoid or suspicious of people I usually trust or think someone is spying on me or planning to hurt me. In most or all situations, it really bugs me when I'm not the center of attention. People often misinterpret my friendliness as a romantic or sexual invitation. My emotions and feelings change quickly to the point that sometimes others think I am insincere. I often use my appearance to get people's attention. People sometimes tell me that when I'm talking about something that I really care about I tend to be non-specific and vague. I think that I am much more likely than most to show my emotions. My opinion, or the way I feel, tends to change depending on the opinions or feelings of those I'm with. I often think a relationship is more serious than the other person does. I have often been told that I have too high of an opinion of myself when it comes to achievements or talents. I find myself daydreaming a lot about an ideal life, and sometimes it disrupts my work. It is hard for me to find people to share things with because generally people are not as creative or unique as I am. I often feel empty and hurt if I don't get the praise and admiration I think I deserve. I generally feel that I deserve special treatment, and tend to get irritated or upset when I do not receive it. I sometimes pretend that I like someone just so they will do something for me. Other people say that I am not very sympathetic to their problems. I tend to be envious or jealous of others, and sometimes these thoughts keep me from getting work done. People are often envious or jealous of me. Sometimes people tell me that I have an attitude problem. I would turn down a job or a promotion because it involved working more with people. I often avoid getting to know people because I'm worried they may not like me. I often hold back my feelings in intimate relationships for fear of being put down or made fun of. In social situations, I worry so much about being criticized or rejected that I can't get it off my mind. I am often very shy and quiet in new social situations. Even when I'm at my best, I usually feel like I'm not as much fun to be around as others. I am usually worried about trying new things or taking chances for fear of embarrassing myself. I often ask others for advice about every day decisions like what to eat or buy. I often rely on others to make major life decisions (jobs, relationships) for me. I generally find it difficult to disagree with others because I am afraid of being rejected or disliked. I generally have difficulty initiating projects or getting things done on my own because I lack the confidence. I often bend over backwards to do things for others, even unpleasant things, because I hope they'll take care of me when I need it. Usually I do not like to be alone because I am afraid that I cannot take care of myself. When a relationship ends, I am always desperate to get into another one, even if it's not the best relationship for me. Sometimes I cannot stop worrying that those I depend on will abandon me. I and/or others think that I spend too much time organizing tasks (such as making lists) that I have trouble actually getting to or completing the task. It is often difficult for me to complete projects on time because I have high standards for myself. I consider myself to be a workaholic. I often have to forego leisure activities with friends or family because I am working. I worry quite often about whether or not I have done something immoral or unethical. I find it very difficult to throw things away even when they are worn out, old, and useless. I often find myself taking over other's responsibilities because I feel it is the only way to get things done right. I feel that it is important to keep as much money as possible in case of a disaster. Other people often describe me as being stubborn or set in my ways. Before the age of 15, how many times did you:
stay out much later than your parents said you should? run away from home overnight? - return home after running away? threaten or pick on other kids? use a knife, gun, bat, or anything else that could hurt someone? did you hurt people when you were not in a fight? purposely hurt an animal? force someone to have sex with you? purposely damage someone's property? intentionally start a fire that caused serious damage? get in trouble for lying or breaking promises? steal from stores, your parents, or others people? rob or threaten anyone if they didn't give you something you wanted? break into someone else's home, building, or car? How many times have you done any of the following:
(IF AGE <20) ...between age 15 and your current age
(IF AGE >20) ...in the last five years
bought or sold stolen property embezzled other people's money ran numbers (i.e. participated in illegal gambling) shoplifted or stolen things done other things that could have gotten you arrested I sometimes lie, make up stories, or give false names to get what I want from others. I sometimes leave my job or leave my residence on the spur of the moment without having a plan of what to do next. I frequently get into fights. I do things that are fun but risky. I sometimes get in trouble for doing things that put the people around me at risk. I often am unable to pay for necessities for food and electricity because I spend my money on things I don't need. When I'm working I often get into trouble for not arriving on time, missing too many days, not doing my work, or not following the rules. I usually don't feel bad or guilty when I've hurt or mistreated someone else. I would say that often I feel gloomy or unhappy. I usually believe that other people are better than me. I always put myself down and criticize myself. I am usually worrying about something. I definitely notice people's faults more easily than their good points. I tend to think that the worst will happen. I am quick to feel guilty or responsible when things go wrong, even if others don't blame me. When I get tired of doing my daily tasks at work and/or at home, I often make excuses or don't work as hard to get out of it. I often complain to others that people don't appreciate or understand me. Most of my discussions turn into arguments. I tend to be critical of my superiors. I frequently find myself disgusted with most of the authority figures I have to deal with. I often talk about how unfair it is that some people are better off than me. I feel that I've had worse luck than most people. Others think that I complain too much or exaggerate my problems. Often, if I tell someone off, I feel really bad about it later and then I take it all back. I often find myself in situations where I get treated badly. Most of the people I get involved with disappoint me or let me down. Often when I leave one bad relationship, I end up with someone else who is just as bad. I find it quite hard to accept help from others even when I know that I need it. During times when I do let people help me, I often work to convince them that their assistance is not helpful or won't work. When something good happens to me, I often expect that something bad will follow. I tend to do things to make others angry, even though I feel bad once this happens. It is hard for me to enjoy fun situations I find myself in. Even when I have enjoyed myself, I do not like to admit it. I often reject invitations to do fun things. I often find myself helping others instead of doing my own work. Even though I am capable of achieving goals that I set for myself, I often fail to do so. I have a lot of trouble maintaining relationships with people who treat me better than I think I deserve. I always sacrifice and do things for others, regardless of whether they ask or return the favor. |
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